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Ik^l^M^ 



MlE!M)m 




J 



{ . 



^ 



I'llACTICK ()]'' SUROEliY. 



THE 



PRACTICE 



or 



SURGERY 



[ 






JAMES MILLEB, F.RS.E,. F.R.C.S.E.. 

t'navin ut diuiivhit to qib hotal qiaimLH furcb u.njiBT fuk bccttlaiidj 
FinniiBoi nr ivwikbt izi tite ErnrvEvrrv uw ibiwiunna t 

CDKElTLtOllJ HtftOVOn TU THE IIOTAL INriKII^IlT ; 
rtC. VK. ITO, 




HIRD EDITION. 



IlliiitrAted by Two Haadred ind Twmtr-Seven fingrHTin^ on Wood. 




EDINBUBGH: 
ADAM AND CHARLES BLACK, NORTH BRIDGE. 



VkCU 



■ 



• ■ • 



iL'IMlI'LbU. rll>T»lP wi H. '.'SO II. ri.AAl, 






PREFACE Ti) THE TUIUH EDiriOX, 



The following Pages, thougli dertigiiatrd by the special 
Title of *' Practice/' really Ciinstitiite the Second 
Volnmc of a Contiinioiii^ Expositioti of Principles 
and Practice, together fonnin^ ;i compete System 
of Surgery. 

The Author, while again thanking the Profession 
in this Country for their favourable rccc:ptinn of the 
Work, takes leave to express his grateful acknow- 
ledgment to Mr, Sargent of Phihidelphia, for the kind 
and able manner in which he has edited the American 
Republications, 



CONTENTS, 



CHAPTER I, 



Oprbatjohh . 



1 



CHAPTER II. 

INJUK1EB OF TnE BCALP. 



BroiBcoftbc Soalp . 

AVoxuids of Ihe Scalp 

Wounds of the Temporal Artery 



7 
9 
12 



CHAPTER III, 










INJURTES OP THE CRANIDU ; AND THEIR CON SEQUENCES. 


ConcQHaioD of the BraiQ . . ^ . . . 


14 


ComprcHHioQ of the Brain 








23 


Coiuprcedon by Exlrarosation of Blood 








26 


ExtravaHatJon bct^vccn tho Bone and Dura Mittor 








20 


EitmvasalioTi of Blood on, or ia tho Brain 








28 


AbaccBB of the Dura Mater 








31 


Practuree of the Oranhim 










36 


FisBuri; . . . , 










36 


Fiaaure at tho Baso of lh« Cratiium , 










37 


Fracture, vithout Displacement 










39 


Fracturo> wilh Displacement 










40 


Punctureil Fructare . 










42 


Fracture of the Eitcmal Tablo^ alono 










44 


Fracture of the lonor Table, alone 










44 


DeprcBaion without Fracture 










44 


Tho OpcrAtion of IVephining 










45 


Woundft of the Brain 










47 


Ijodgment of Foreign Bodiee 










48 


Hemia Cetehri 










49 


Puaccat«ua Capitia 










ni 



CHAPTER IV. 
DISEABEB OF THE BCALP AlfD CRAMUll. 



Er7npe]aB of the Scalp 
TuiDOUrtf of the Scalp 
Pericranitia 
Ailbctiona of tho Cranium 



53 
55 

fi7 





CONTESTS. 

CHAPTER V. 

AFFECTIONS OF THR OEBIT AND ITS CONTENTS- 
T. Affhctioms of the Orbit. 



Orttitnl Influnmation 

Wonndaof IhcUrbit , , . , 

ToiDoars of the Orbit . , . . 

II. Arrmonasa of the ErEuoa. 
Ii\)anes ...... 

Oplithalmui Tomi , , . . . 

Hordeolum ,,.,,. 
Enn^Bfed l\]Tiii}llr9 ..... 
Hypertrophy of the Upper Ejtiid 
Cancpr of tlie KjoUJh , , . , 

ClOftnro of lU'-'Ej-elUn . - . . 

T^^plilhalo^nn . . , . 

Ptoaifl .,..., 

TricbiAfiiB ouJ DieticluaBia , . , , 

Entropion ,.».*■ 
Kctropion .-.'... 
BkphnroplDStica ..... 

TIL AlfKCTTONB OF TPB Li.CHETUAt ArfAlATDfi, 

EpiphorA ,.,../, 
fnHwamal'frj Anr:f^tinrLd of ibc LacbrjUfiLl Bac , 

FiGinln LachrjEualia . . h 

ObntractioT] ollha Nand DuLt , . - , 

OblitcTMidn smd AbFictiCf; of Ibo Nasal Luct , 

Dnun'ulItbeB , . , 

AQi!ct!ona of the Lochrynml Gbnil 
Encjuilbis ... 

IV. Afpectiom op this Etedau., 

1, AfFKCTIONS of the COSJI'WLTIVA, 

Simple Conjnactivitis 
Pumlpiil Conjuuclivitja 
StmTnrnift Conjuncfii'itiH 

Granular Conjunctiva . 

PlerygiiiiD 

Fanuiia 

3h AFrEcnoHB or the Cokhea. 

Comoiti* , 

AbflCDBH of tb^ Contf^n 
Ulcflr of ibe Ci>mca 
OpAcIiicH of tb« <>)mL*H 
Stapbybmn of thn r^jmea 
GonicAl CorDcn 
OverlKat^Dlion oflho rJomca 



txon 

62 

6Z 



M 
65 

66 
66 

67 
flB 



W 
^0 
71 
73 
74 
76 

76 
77 

79 
61 



83 



84 
87 
9t 



04 

66 
96 
S9 

lOO 
102 

in2 



C0NTENT8- 



IX 



5. Amcnmn or th« Scudtonc CoAr 

Sclerotids 

Stapbjlooift of the Sclerotic 

4. ArFEcnoss of the Cooboid €oit- 
CbonadiliB 
MoBCje VolitADtei 

A. Afpectiovb of the Ibis. 

IriJia .... 
ChaDge« in the PnpQ and Tria 

Occliuioo of ibe Papil 
Fonn&tiuii of Arttficio] Paiol , 

6. AFFicTnovs OF TBB Bsmi. 



Betinitu 

Amaurosis 



7, ApFEcnon of the CtrsFtAhunz Lsso amv Cipsule. 

Calaract . . , . . 



6' APFEcnon of the HnHousa. 

Hydrophthalmia 
Sj^chf Hi§ OcoH 

OUacoma 

Ophtfaalmitis 

WaaDilsoftheEjebftll 

Tomoan of the Ejcb&U 

Eitirpatiop of the EjeUtl 

Coa^oilal D^ficieocj of the Eyeball 

StmhisniQe 



FAM 

lOS 



IM 
106 



lOG 
10» 
110 

no 



lis 

113 



116 



Itt 
1» 

123 
123 
124 
124 
1£6 
126 
12$ 



CEAPTEB VI. 



AFFECTIONS OF THE NOSE. 



Fmctnro of ibe Nud Bones 

Uporoa of the Nose 

Kaaal Polypna 

Rbjaolltbes , . . . 

Epietaxia . . , , 

The passing; of Nasal Tabes 

ForcigD Bodks ia tbc Nofitnla 

Congestion of the Scbncidcriiui Memlrane 

AbHcesi of the Septum Nariuni 

TTlccrs of tbc liostnls 

Ozena .... 

Lnpufl 

Rhiaopl»tics 

PviUl RiSBloration of the Nose 



130 
130 
132 
135 
136 
138 
138 
139 
139 
140 
140 
141 
142 
145 



UONTBNTS, 



CHAPTER VII. 
AFFECTIONS OT THE SUFEKIOR HAXILL^. 



Oollectlali uf fluid in tli? Antrum 

Abic«u of ibe Anlruiii 
Palypim of tlie Antrum 
Tomoiira of tUo SupiTior niii:[i|[a 
ExlErpitUon of tto tiujwriDr Klaxillfv 



M8 

119 
150 
l&O 
161 



CHAPTER VIU. 



AFFECTIONH OF THE fACE, 






WounJfl of the fr'ftcs ...,,,, t5fl 


WnrlH bf tta Focfl 


* 




165 


EryeipelM of the Flco 






U& 


Spasm of the Face - 






!&5 


Ni'uraljjia oftlio Fnco 






1S6 


Tumoura oflhfl Cheek 


. 




!» 


SiauH of iLe Clwck 






167 


Saliyary FirtnU 






Ifi? 


FVacTure oftLc Oa Malm 


. 




150 



CHAPTER IX 

AFPECTIONa OF THE LIPS. 



Ilun^tJji 

tjlc^m of f hu Lips 

C*nerma OriB 

CheilopluUos 



159 
161 
104 
164 



CHAPTER X. 



APFECTlOfCfl OF TH£ PALATE. 



Cnugcoital Lkv6ciai]cy 

Ukur Aud EtfoliACioa 



1G5 
166 
168 



CH.Un:ER XI 
APFECTIOKS OF THE TRETH- 



Crowded T««th 
C-an» of Ubr? Tralh 
TovLliiKh 

tittmctioti i>f Tirclb 
llcnnrrfaagfi after Eiirocitiju 
Ttfur on the Tc«i^i 
Ttcrifinii of iIm Gtiib* 
iDJttriea i>f ibe Tf«i1i 



169 

les 

ITO 
171 
ITS 
173 
173 
ITS 



UONTBNTS. 








Xl 


CHAFrUR XII. 


AFPGCTIONfl OP THE JAWH. 


PAOV 




Epulis , . . . 










174 


Tumuun of the Lower Jaw , 










175 


Eitirpation rjf ilic Lower J»w 










176 


CaricB ftnd N4:crng]>« of rUe Lower J&w 










179 


Fracture ofihr L"WcrJaw . 










179 


l>iHlocaljim of [he Lower Jaw 










180 


AncbTlosis of the Jaw 




- 






181 


cHAPTEa xm. 


APFECnOKS OF THE TONGUE. 




Woundu of tbo Tongue 












181 


Llcer» of the Tongue 












188 


Hjpcrtrophj of the Tciigii« . 












183 


Tnduration of the Tongue 












184 


Erectile Tumour of tLe Tongue 












t84 


BeiDOTol of Poriioni of the Tongue 












184 


Diviaton of the Fncnum Lingma 












185 


Bauuhk 












186 


Tumours beneath the Tongue 












186 


Sdivar; Concretiona 












187 



CHAPTER XIV. 

AFFECTIONS OF TUE UVULA AM> TONSILS. 



(Edema of the Uvuta 

Elongation of the UtuIa 

TonBiimifl 

Abflceaa of the Toniiit 

Ulcers of tbeXonsiJfl 

Hypertrophy of the Tonaila 

Malignant Diseaso of the Tonsils 



188 
IBB 
IdO 
189 
190 
190 
192 



CHAPTER XV. 

AFFECTIONB OF TUE THARYNX. 

Pharjnsgitis . 

Pbaryngeal Absceis . 

Stricturo of tbfl PharyDx 

Spasm of thi' Pbarynx 

Paraljsii oftbo Fhiiryn* 

SflCculritc'i Pharynx 

TaiDonreof tbe Hiaryni 

Foreign DoJks io tbo i^rynx 

Th« paidDg of InstruEoenU hj tbe Pbtryox 



193 
193 
194 
195 
I9A 
195 
19& 
196 
196 



^ft XJi (.ENTENTE, 


^^P CEUPTEK XVT. 


^^^f ArrECTioKfi or TftE (EaoFQAOua. 


^^^V tAoa 


^^H Siriduri; ofthe (Esopba^B - ....,, 1D9 


^^V Fureigri Bodii^d iu tliL' CEgopLa^pfl .,,.,■ 300 


^r fTliiopKEigiitDriij ........ 902 


" Piby uf llie CEftopbagQ.i ....... S03 


CHAPTER XVII. 


AFt'ECTJO?iS OF T[]£ EAR. 


Foreign BoJi^ja .....--. 30* 


PMyjuifl uf thfl Ear . 






W4. 


Otitifl .... 






206 


OtorrhtEfl . . . , 








sot} 


Abs<:rH[i unb? MnBloid Civile 








BOS • 


OtflTj^in .... 








208 


Doafurcia .... 








209 


PerfornlioD of the McmlriiTia Tympiuii 








Bl! 


Ilemorclnigt: froni tiic Ear 








Its 


Hyptrtnipliy or iLe Auricle - 


- 






218 


Oioplaofica . , . - 


. 






aid 


CimgciiiUl OccloHion of the MeftLm 






S13 


COAPTEH XVITl. 


AFFECT[ONS OF THE PECK, 


Qianilulnr Knlnr^'tnenl And AbscCHB ..... 116 


^^K Homaloctlo cf iW Nock 






916 


^^^ TuiiiuurH of lb? Xeck 






316 


^^M OjitDing of tie EKUmAl Jugular Vein 


, 




317 


^^f TftrtK'il\h .... 








SIT 


B Wournia ftf tijt ThrifBt 


. 






916 


P Bronclioluiny 


, 






233 


FrTeigtt DoilioE in tliD Windpipe 


■ 






3fi8 


Aaplivxia . , . - 


, 






SS7 


ligiinGH cif tlic Ijftryn* 






92B 


The jici:iiJi.*ntrJ Hvailiiwuig of b(dliu|r ^nter, acids, or olhet 


iriunt 


duidii 


229 


Spasm of iLc Oluttia .... 






330 


tAryngitis . . , , , , 






330 


I. AcQtv Larjngilia .... 






3S0 


a. Lorjngilia Siinjilejs 






3S0 


fr. Laryngitis (Ed^rantoaa . 






231 


c, LaryngiliB FibrinoHa 






»3 


DiplitlicritiH^ nr Cynanchu Ucmbranncen 






sa& 


d. Lftiyngitia Punilpnt* . 






235 


II. Chronic Laryn^iia . - - , 






9B6 


a. Thickmng of Mucona Membranu 




330 


6, FuUicular Ciacntii' nf larynx 




9S6 


c- Chronic fEclpmii Ctlottidii 


S3ti 


d. Ulvcralion olibe Lnryns 


337 



COtTTENTa 










XIII 


« 


PA01 


Wartfl of the Laryni 


239 


Stnctnre of Ihc Wiailpipe 










240 


FonDAtioa of Matter near the Larynx 










241 


LuTyn^T^^'i'y 










243 


Trachei>tomj .... 










243 


BroDchoctle or Guitre 










246 


TcmourA over tho Thyroid GUod 










249 


Enhirgemont of the Thyro-hyoiJ Barsa 










249 


U«rDLA BronchntjB 










250 


Disease of the Cervical Vertebnc 










250 



CHAPTER XIX. 

ATFECTTONS OF THE ARTERIES OF TUE NECK AND SDPERIOR EXTREHlTY, 



DcHgation of the Carotid 
D«ligatioD ofthv Artoria Anonjma . 
Dcligation of the Sabcljivlflii 
Deligntion of the Axillary 
Dcli^tion of the Htmicral - 
Deligalioa of the Arteri«J4 of the Forearm 
WooLidfl of tho Palmar Arch 



262 
203 
254 
25a 
257 
258 
258 



CHAPTER XX. 

AFFECTIONS AT THE BEND OF THE ABH- 



Veneaection , , . . 

Accidents of Venesection 

Affectjona of the Burau over the Olecranon 



260 
261 
2G2 



f;H.\PTER XXI. 



AFFECTIONS OP THE WRIST AND HAND. 



OongHa, and Thecal Collcctione 

ParODjthia . , . . 

Onychia 

OnyxiH , . , , 

ContTOctiou of the I'nlmur Fuscia 

Tumours of tlie Metacarpal Bonea and Phabngea . 

Other DiKeaai>s of tho ^letaearpal Bones and Phalanges 

Hypertrophy of the fliigiTa .... 

Congenital Deform itios of the HonJ 



2G3 
263 
265 
266 

266 
267 
267 
268 

269 



CHAPTER XXII- 

DISEABES OF THE ARTICULATIONS OF TDE SUPERIOR EXTREMITY. 

Diaeaac of tlio ShonlderJoinl ...... 270 

Rcseclion of Ihn ShfiuMer-Joint ... 270 

RcBCClion of the ElboW'Joint ... 271 

Resection of the Writ.1 ...... 27.T 



^^^^^B rOlfTSNTS. 


^ 


^^^^V rriAPTER 


« 


^^^^^P tnjuaiEa or toe suft^HioR extremity. 




^^V FlADTUHtb. 




^^^^1 


HQS 


^^^H FraciuTfl of tkc GUvidn . . . , 


874 


^^^H FraDturo uf tht" Holy nf tho Sc^apnla 


97fl 


^^H Fracture (irth^ Acrottiion , ^ . , 


S76 


^^^1 Froclcinj of tlie Coraooid FriKit-u 


tT6 


^^^H Frochiii^ cif iht ^i^k of iLl truapuLa 


276 


^^^B Frar'tiirp nf tho Nook of the* Humpnitt 


yi7 


^^H Frn^ture uF rhc Shaft of tlio Huidciub 


97Q 


^^H Frai:ture oFfhc CoTnIykB uftbe Humtniti 


380 


^^^H Frvtnrc of Clic Ulnu . . . . . 


B80 


^^V FroctUFQ dF the RhJIuj . . , . 


281 


J Fractiiro of both fiatlitin athI Ulna 


ass 


r Fraclun? of the Mttucirpol Holies 


»3 


Frm^tun: of (he Phalau^B . . * , 


>84 


IhALUC&TEUNti. 




rHslorftlion of the CUncIo , , . , 


384 


DiBplnccment of the Auglu af thi- Sortpuh 


3S6 


DialucBtiuli of Ihu Ilumtruii, ut lie Shoulder 


185 


Difllocallon of ihu KndiuA 4nd I'lnn, Jit the Elhow 


388 


DidlL^culjuii of tha Uhii, at the Elbow , 


389 


Ui(il<>cn[h<" of the tiadiuH. nt the Elbow 


389 


UinlucuCmij uf tbv Wi-ist r . . - 


390 


Diaiocalioa of ihi- ringora , . . . 


391 


Dialocalion oflho Tliuiub .... 


391 


CHAPTER XXIV 




|}fJUKlES AKn DiaEAfi£8 OF THK ^yiNK. 




OiiicLflfcifln of ihe S|jitiul Cord .... 


. •im 


ConjprcBaion of ibe gpiHiil Cord . . . , 


393 


FrBGtara of tie Spmo . . , - . 


*iuu 


LHBlocalion of ih<i 8|iino , , . . , 


'/Ui> 


Luti'riif f.'iiTVUturu of ihn Spine , . . . 


397 


DiBi'nao of thi- Dodiu* of (hi? Verlebne . . . 


300 


Lmnbnr mid I'hoh AhaciiBS . . . ^ 


303 


1 ^jiLEia Ditid^k ,.,..., 


303 


1 HaLignaitf DiHoiuo of tha H|tiiiD .... 


BOi 


^V nilAPTEB XXV, 




[ TNJlifllRa ANR DtfiEABEB liF THE CHEflr. 




^^B FrActuru uf tbe ILiba . . - . . 


aoe 


^^1 Dijdocation of the Rlba . . , 


SOT 


^^U Fracture of tho Stonmni 


SOT 


^^H CferioB anJ NecrEjaia of tLo Rib« and Slcnnini 


307 


1 ■"""-" 


BOS 


1 


^ 





COSTENTS- 


XV 


Wuundfl of ihfl Cheat 




308 


Hfcmalo-Thorax 




310 


PneumiyTliorax 




311 


PnracpnlcHis Tliorneis 




311 


Wouodu or tbe Uoart 




313 



CHAPTER XXVi. 



AFFECTIONS OP THE UAMUA AND KAMMILLA. 



Irritable Mamma 


■'Ma qi 


tr nj«a 


miii#A 




3U 


&Iikmmitt», Acute Aod 4?]ironk 










314 


C^roi^ic AbBce§ii 










315 


Lacteal Tuioour 










31G 


llTpcitTophy 










316 


PemluloiiA Breuftt 










316 


Prtrtinl Hjpcrtropliv 










310 


VariuD Tiiiuoura nftbc MBmmii 










317 


Eitiqiiilioij uf the Mamma . 










319 


Affection! of the Mammilla , 










310 



CJlAPrER XXVII. 



AFFECTIONB OF THE ABDOUEN. 



AbscfiBB of tliB Abjominal Pan<'t«B 
Tnmoun uf the AbJomiaal PatietcH 
Bni!be of tliu Alidomen 
Wourula ufthf AbUonien 
Anitii-iAl Aqub 
Fscal Eldlula 

Pflvic AbflCVBH 

Kctro-Ulerinc Sanguineous Tumour* 

Ovariiiri DropHj nnd Tumours 

Fibruus Tamoun oflbc UteniH 

Gastrostomy , 

Gatttrutomy . 

AJfecliona of tho Diaphragnj 



321 
323 
322 
3^3 
325 
327 
327 
328 
329 
330 
337 
337 
336 



CHAPTER XXVTIL 



BERN1A. 



Reducible HcniU 










343 


Im-dneible Hernia - 










345 


Incarcerated Hernia 










340 


Strangulated Hernia 










347 


Ublitiue-iuguiuELl HiTiJa 










358 


Veiilro-ingtiiual Hemia 










361 


Femoral HemiA 










361 


L-mbllical Hernia 


, 








304 


The other Varieties of tlniita 


- 








365 



XVI 



(JONTENTB, 



CHAPTER XXrX. 

AFFECTIONQ OF THE RECTUM, 



AbicesB Exterior to the HecCtun 

BectitiB 

FUtola in Ann 

FtasuTV and Llci^r of th« Anus 

HflmorrhoidB 

Foljpus of the BeotDDJ 

ProlapsaH Ani 

Btrictare of tho Ttectum 

IrriUblo Rectum 

Bemorrfaoge Ironj the H«ctiim 

Ti^uriea of the Rectam 

Foreign Bodiei in the Bectum 

Imperforate AauH 

Artificial Adqs 



867 
367 
368 
372 
374 
378 
378 
380 
383 
383 
384 
384 
3S5 
3S6 



CHAPTER XXX. 



CALCtLOUH DI3BA8E. 



UrJimi7 Calculi 

Formation and Vorietiea of Calculi 

Rona] Calculi 

Vesical Calculus 

Treatment of SCono in the Bladder 

Lithotripsy . 

Lithotomy 

Vanetiefi in Lithotomj' 

PaJliation of Veaicol Calculus 

Urethra] Calculus 

Prostatic Calculoa 

Oalcalns in the Female 



401 

406 
40B 
413 
418 
422 
434 
436 
437 
438 
439 



CHAPTER XXXI. 

AFFECTIONE OF THE BLADI>CR. 

Cystitis 

Irritable Uladdor 
Hematuria . 
Incontineoce of Uriae 
Retention of Urine . 
Retention of Urine m the Female 
Puncture of the Bladder 
EjctrnvnaBtion of Unne 
Ipjories of the Bladder 
Tumours of the Bladder 
Displacement of the Bladder 



441 
443 
445 
446 
448 
454 
455 
456 
458 
459 
460 



CONTENTS. 



XVII 



CHAPTER XXXIl. 

AFFEGTIONH OF THE FROSTATE. 



ProitBlitift . . . - 

AbAcfMts of iho ProsUte 
Simplo Enlorgomont of the ProBtato 
M^ignikDt Dioeaso of th« Prostate 



461 
4C1 

465 



CHAPTER XXXIIl, 



THE TEKEREAL mSEA9E. 



Gotion-hcca ...... 






4ca 


G<inoiThcca in tlio Fcmalo .... 






475 


Syphilis ...... 






47a 


Tho Simple VonereiJ Hcor 






477 


Tlio ITker wjtii ElcvntcJ Edgflfl, nnd ha Rcaulta . 






480 


The HualL'rijin, or Truo Chnncrt- 






462 


Th« PhagcJfl^iuc and SLougking Sorea^ and their Results 






484 


OondjloniJk ...... 






48S 


Bnbo ..... 






490 


A general View of (ho Suljcci 






402 


HiQ Uhc of MercQTj id S^phiLiK 






497 


Syphilis in the ChilJ . . . . 




503 


Syphilis ia the FemaJe . . . . 




503 


Fsecdo-Sjphilis ..... 






503 



CHAPTER XXXIV. 

AFFECTIONS OP THE URETHRA. 

Btrictnrc ...... 

Urinous Abpccflft 

Drinary Piatala . . , . . 

Lacention of the Urelhra . , , . 



518 

520 



CHAPTER XXXV. 
AFPECTIOHfl OF THE TESTICLE. 



Orchitis 










521 


I^Dgiis of the Testicle 










553 


BcmfolonA Tcstieto . 










525 


TuiDours of tho Tcsticli^ 










526 


Irritalle TeHtielo 










527 


Atrophy of the Testicle 










527 


Hydrocele 








- 


528 


Hydrocelti of tho Oo^L 










532 


Un^matocele . 










5S4 


Qrsocole 










535 


Tumoiirt of the CopI 










536 


Castration 










537 


ImpoteDCO 










538 


Siwnnatorrboca 










539 



^^^^m 


^^M CEiAPTEIi XXX^VL 


^^B AFr£CTIONB OP THE BCROTUM A»D PEMB. 


^^^m r4ai 


^^H KryHipelaa ofthe Scrotujn ...... ^ Ml 


^^H ElcipbAntiaeid of the Scrotum 








541 


^^H Chimncy-SwG^piir'n CuDcvt . 








M2 


^^^1 FrLupI^im 








M3 


^^H Phyiudflia 








544 


^^^m Pur(i[>hycnoaiH 








545 


^^H Uyptispndias 








547 


^^H H^peTupiidias 








547 


^^V Impi^rfoTato Urethra 








547 


W Moli^iiot Diflcaae of the Pf?tii» 








547 


^L AtapaiAtLon of the Pt^nifl 








548 


^m CHAPTER XXX^ai. 


■ AFFECTlGHB OF TUE FEMALE GE!4ITAL OHGAIIS. 


Inllanunation of tbo VuWii ,..,.,, 550 


Abfli^ppa of the Vulva , - , . 


' ^ 


551 


ThrombuH tif ifm Vukn . , . , 






Ml 


W»rly EnreHfcnMfl uf itc Vulva 






55^ 


Oi>EtDg Tumour of iht LaMum 






552 


Pnirilua of tho Vulva . . . , 






553 


Mfllifrnant Ulcer of Estunifll Pnrts . , ., 






553 


Tumourfl of ibo Lnbin . . . , 






553 


Flcaby EKi:rc&cGiico iu tlio Orjfico of tha Urotlira , 






553 


I^acerBtion of rermeum . ^ , . 






554 


Vftginul FiMtuU . » . . . 






554 


Striclura uf Ilia Vngina , , ■ , 






657 


OblUeratioo of the Vagina . , 






558 


Imperforate Vngino or Hfumn 






558 


Foreign BiMlioB ia thu Vagina 






559 


ProlnpauB of tbe Vo-gina , , , , 






550 


Tho PuaiD]^ of ibe F«ma!o Cath«ter 






56U 


Pliiggbig of tlio Vagina . . - , 






560 


LeacnrrbitA . . . . 






5G1 


luvcrbion of (he Utomii . . . m 






564 


ProUpaua of the Uteraa , , , . 






m 


DJaplacenientfl of tho Utcnis 






51^8 


Stricture of the Cgrvii Utori 






569 


UtpHnti P'llvpnn 






570 


EitirpalEoD of ihc CerrTx Uteri 






572 


Mftlig^unt £>i§e«Be of the Uterufl 






573 


CHAPTER SXXVIII, 


OPERATIONS ON TTEB BLOOD-VEttSELB OP T(IK LOWRH BXTnEMlTY, 


Migotion of ihc Aorta . . - - . . 577 


DeligaliorMtfibe [Iriui . . . , , 079 

1 



CONTBNTS. 



UX 



Dvligjhtion uf tlic tVoxor>]H 
DGligAtiaiL of the Popliteal 
Ueligntioti of the Tibials 
Deligation of the P«roii««t 



Ml 
584 

5B4 
5S7 



CHAPTEB XXXIX, 

AFFCCT[ONS OF THE JOINTB OP TUB LOWEU EXTREMITY. 

Morbua CoiariuB ...... 688 

Eeaectioii of the HipJ^oJnt ,...,., 696 

ChaDgQ of Fditq in the Hip^oint ...... 6DG 

AfiectioEiH of the Knee and HoTu ...... S97 



CHAPTER XL. 



INJURKH OF THE LOWER EXTREMtTlKS. 



FHACTDaUd- 



FractQreB of the PelTia 
Fractnrea of tho Femur 
Fracture of the FatclU 
l<Yactiirc» of the Leg 
Fractnrea at the Ankle 
Prftctureft of the Foot 



DieLOCATlONB, 

Dislocation of Che PotTis 
Dislocationa of the Hip 
Dielocationo of the Enee 
DiBlocalionfi of tbe FateUa 
Disloealiona of the AnkJo 
DislocatioQH of the TarooB 
Didocntion of the UetatoiHaB 
Diolocatioa of the Toes 

Suhluxations and Spmiiis of the Lover Extroinitj 
rnjuries of the Tendo Achillia and GaslrocneminB Muscle 



508 
599 

006 
607 
609 
610 



610 
Gil 
61S 
619 
619 
621 
623 
623 

624 



CHAPTER XLL 

AFFFCTIONa OF THE FOOT, 

Talipes 

FLat-foot 

PodeUtoma 

Corns and Bonionn 

OoTxifl and Onychia 

Elxoatoais of the Distaf Phalaax of the (ireat Trie 

Contraction of the Toe< 



G27 
631 
632 

632 

634 
634 



XX 



CONTENTS, 



CHAPTER XLIl. 



AMPUTATION. 



AVPUTATIOHS OF TUB ScTFESIDa EXTBUHITT, 

Ampatation of the FtDgen 
AmpntatjOQ of the Tliumb 
Amputation oftho WHst 
Amputation of the Forearm . 
Ampatation of the Elhov-Joint 
AmpaUtion of the Arm 
AmpatatLoa of Ihc ShonlcIer-JoiDt 
Amputation of the Scapula , 

AUFtJTATlONB OF THE IjOWEB ExTEEMJTT. 



Amputation of tho Twn 
AmpututLonB of tho Foot 
EcBection of thp Ankle 
AmpulatioD of the Anklo 
AmputatLoJi of (he Leg 
Amputaliou of llio Knee-joint 
Amputation of the Thigb 
Amputation of the Hipjomt 



PAOE 

fi40 
l>43 

645 
647 
647 
648 
649 



650 
650 
652 
652 
654 
656 
657 
658 



Affections of Stnmpa 



659 



THE PRACTICE OF SURGERY. 



CHAPTER L 



OPERATIONS. 



It ifl a favourito phrofio by which opertitions are stigmatized aa the 
" oppmbria of surgery," Notiting can be more nnjiist. Safely and 
expeditiously to rctnove parta wUlcli aecidenl has rendered tutuUy use- 
leBG, and wLicb woiild prove highly injurious it' longer aitac-lied to the 
body ; to take away rliftea&ed formations, or other noxious fiubstauccB, 

and, at thf, e^peu^e of auffi^riiigf t:uiii purati v^ly brief and blight, to 
dispel torture which hiid rendered e^iMence s. burden for previous 
weeks, monlhB, and years ; to accompliBh such results, \s alike cri^di- 
tftblo to the operator and beneticial to the patient. It is not the 
operation — but the opynition uns^^aBonahly, unnecessarily, iinakilfiUly 
performed — that brings disgrace ; and to I'efraia horn operating when 
we are pUinly and j>eremptoriIy called u;>Qn to do tw, woidd involve not 
only oppruLKum to Eurgery, hut guilt and shanie to the surg;eon. In 
former times, it is true, operations ^ere the dlrtgraceof onrart. Knives, 
hot ironfl, screws, files, gimlets, gx)uges, hammera, and saws, were em- 
ployed with cruel and ignorant recklefisnesB. Of late years, however, 
every good surgeon has sought not only to simplify and diminiaU the 
number of iustmmeutSi but also tu use them as selJcm as possible. He 
does n<^t Levitate to employ them, v.-hea his kuowkdg^- aud experience 
intimate that tiiey have become indispensable ; on the contrary, he will 
then prohubly be urgent in their application, knowing that an early 
wound may save mncli afior-flufTering. But, in the first place, he ^vill 
exert all hie skill and all his powers, by milder measures, so to counteract 





3 UPKBATIONS. 

injury aiid r^fjtraau dineju^o, us to Bupi>rGodo tlie aecesntty for operaUni^. 
To fffecl ttifi, IS (limbtlpsa tlio tme truitnpb of lus iirofessinn ; and lo 
this triiimph ho often Attains. But he must be Utopian indeed who 
Cftn seriously lajw that the poriotl A\ill ever arrive^ when opernlioaa 
shall have altogether ceased to be required, MoJern fiurg^ry, accord- 
inglj, while uuxiouti lo Hiult the ueec^fiitiea for operatioo, is uciL the 
Icee ftwaro oi its importance as o. meanB of cure; and has not ooly 
dippoted attention tovartla ilfi improTf!men(, but also extended ilB appli- 
CAlion, and with the happiest result, to diseases formerly witliout 
remedv. Mai:y patienls, for example, are Dow by the knife freed from 
morbid growths and natural deficieucies, who were formerly left tn 
ho^ielesG prey lo liefonntly and diseajie, 

A ppeminent causo of modern iniproveracnl in the art of operating', 
is an increased Eiioplicity of the infitrumeuls, thc;ir arraug'ement, aud 
use. On this snhjecl, one who wjjfi pre-eminently dletinfafnij^hed among 
the lAptrators of the present day, observes:* '*Our amiamentaiia 
should contain simple and eflicient instruments only ; the springSi 
grooves, notches. And curies, st'emiug lo be chiefly iult-ndt-d to com- 
ponE&to for want of tact and Diimual lic^ic^nly. The apikOT'Ltne, tboii^h 
simple, oug-hl to be in gT>od order^ and should always be placed within 
easy and convenient reach of the L>peralor, so that te may be in * 
great measure mitependent of ibt^ !i>okers-on; who, owing to anxie^ 
or curiosity, hurry and a^t*lion, are m^t to hand any thing but what 
may at (he instant be required. He ^\U1 consider well what place he 
tkimself may inoel conveniently octnpy tUiring the opeiution ; and, 
liaving obisdneil proper assistants, he will make sure tbat they all 
DDderctanLl whui is esj^ecled of tbem. In short, before he veoiures to 
begin, he will ascertain that every thing is arranged, and in proper 
order ; more particularly, that the cutting instruments have good 
pointy ibat tlkcir edge^ are kcH^u, and that the joints of forceps and 
erissitrs aiovid fr^oely and readily. The prini^iple, too, on whicb the 
instrtment is made lo cut r^hoLdd be well considered. Every knive is 
lo W Wkod qion as a fine saw ; the leetfa of some are fet for^arde, 
and these cut best ft\>m |x>Tut fo heel, as does a razor ; bnt the greater 
nunil'er are set in- ibe opposite direction — for example, the common 
scalpel and blstoiirj—^nd act efficieEidy L^nly in being drawn frvm 
heel to jkoint. 

^'Tltc skin, and in many instances (he subjaevnt paiia, ahonld be 
divided al once aiid completely, by a single ineision made ligbtlr and 
rapidly — the }»ar[s Uinji; jilaci^I in a slate of tension by the fingers of 
ibe suTf^u or <>f an assL>1ant — for the |>ain es^vrienced ia in pro[»or- 
Ikon to \\ie pn-^itre uid tardtntr^ of movement in the iustrntiienl 
applied. Partial division of ihv skin, in (oils U£t at each end i>f an 
it>eisi<»n, is also to b* avnideil ; for the pain <if sooh a cut is unoeeefi' 

* Lotos, OperaiivT Siu^vfj. 



OPBHATlONe, 



pre 

mk.. 



snrilj severe i and, bcaiclee, Hucb notinds ore not so available, oa tliey 
woull othcrivise l>e, for the intended purpoBo of evacu^ihi^ Hunl^ foi 
ptfrmittiag the estraction of toi-eign bmlien, or for Iha dissection nf 
inorLid growths. Also^ llie pausiuj of a surgeon id tlie midst of a, 
liisscction, and tiie rewrt to treah ami more extensive ineisioiis nf tlie 
riurfact?f is not only always iiwkward, but attended with additional ami 
uijuecubsarj \miu lo the patieiit- Everj enKiuf^ iimir«incjjt bIuiuJJ be 
well bjilAnced, and placed in a steady, Bmotfth handle ; the point shotdd 
either bo in a line with the back, whit!h on^'ht then to he perfectly 
Gtraigiit, or both edge ^md back shouUI be equally couvcx, with tlie 
point corresponding to the niiJdle of the hlnda 

" The form and hvzQ of the instrument ought alwnys lo be in propor- 
tiim to thi< extent of the proposed iQciflions, as regcirda both their 
Icngtb Lind their d<>pth : nothing oan be imugin^d taara cniel and 
reprehensible, for example, than an attempt to remove the lower extre- 
mity of a fall grown person with a eommon scalpel or disscctbig knlfe- 
If ftD extensive incision is necesfinry, an instninient should he employed 
poSKessiiig length of edge siifGi^ieiit lo separalu the juirla smoothly and 
iprickly, Shimld Uie operator, on the contrary, be reijnireU lo oil on 
important parts — to |>erform a delieate diss*icilii>n of the living (iesiios — - 
he will choose a short-bladed iostrument, with a handle rather lon^ 
and veil rounded ; and, after the siiporficial intisions have been effected, 
he will hold it a» he would a writing pen, lightly but firmly, eo that 
he can torn the edge, and cut eitlicr towards or from himself, as occa- 
sion may n^quii^. A eoiall uelhmade ncaipel, with a good [Hiint, and 
lesB oonveiity than t\ios*- usiiaKy employed, is tho instninit^nt beet 
adapted for such a pnrjtose. Grooved probes and directors ahoiild be 
Hsed as little aa poaaible. With a little prictice, inHsions may bo 
rawle upon the most delicate parts wiihout risk, one layer being cut 
after the other. And if any instrument is wanted to make the 
proceeding more eafe — if the closely invcfiting faacie of a henual 
tumour, for example^ are lo he cautioiiBly niitied — dis^Heeting forecps 
will he foon<l the moat convenient iiislrument for elevation provious to 
incision. 

** In dividing the skin, the kntfe, whether a scalpel or a bistoury, 
IB ro be held and entered with the point and blade at right angles to 
the aiirface. It is carried wilh a decided movement down to the sub- 
rLiIaneuUM eeUuIar ttj^ne ; the blade is then inclined towards the prirt 
to be divided, aud by n rapid and slightly sawing motiou — as little 
(resBUro }>eii)g applied as possible — dirision is ijffccted tn the desired 
leut. The inriaion is finished by m illiilra^inn; the knife in a posi- 
n perpendicular to die surface, so us lo dividu the entire ibickness 
of t)iG ftkin, at the extremity aa well as at the origin of the wound. 
For deicterously effecting snch manipnlations, the fingers mijst b* 
educated ; and diligent practice in the dibBectbg-room will be found 
the best foundation for surgical dexterity, as it Ib for sound surgical 





4 Ut*EKATlOn8. 

knowledge j it la only when we Ijavc ftcqnired dexterity on ibo dead 
aiilijoct i\iiii wo can b© Justified in inltrfi?ring with Ibc living.'' By 
practice, the pnpil will be enabled 10 11^ cilber band almost eqimlly 
well ; and none nboiild neg'lett to att^iio this power — for an ambidex- 
troua sup^'on [KJsBessehi ^itl juiv.intag;efl as an operator. 

While an L>rdinary degree of cxpcrlncKfi is within the reach of any 
one, who will industriously seek fur and improve the opportnnitiea for 
its ai^uiremenl, y*^l a eertain combination of nahiral qiiul ifiefttiona is 
undoiibtiitlly necessary to the alluinment of pre-eminence in epcmtire 
Biirgrry; a great oj>enitor in oue respect resembling a gmai i«et, — 
"nascitur, noii fiL" The innrortance of Lhese natiirul gifts ilid not 
escape Cebiis. ** He miisi be yoTUjg^ or ai most but middle-aged/* 
Bays he, " and have a stnmg steady hand, never Biibject to tremble. 
He must h*f atubidextroiia, and of a quirk, clear sio^hL He most be 
bold, anil so far void of pily that he may have in view only Lhe cure 
of hbi whntn he ha^ taken in hand, and not, in compassion to cries, 
either make more hasle than the case requires, or tut less than ia 
necessary, but do all as if ho were not moved by the shrieks of bia 
patient. " The c^Kihiesi^ aad courage thus iucultated are among tbe 
moHt vahiablo nutnml gift^ of the surgeon ; and it ^ou1d be t^ell^ too, 
did every (inlieul rcmeudjer tluU Ihey ai-e equally important in bimBelT, 
for on his steadiness and paiience under suffering much of the celerity 
and success of an operation may somplimes dei»end- 

In the present day, lioAvever, the ojwraior is much less dependent 
on hi^ fMLUent than he was woat to be ; in the great nuijority of oftsea 
the latter bi?ing absohiti'ly p:ii^»ive in liis bands, ln-caiiiu* quietly recnm- 
bcnt under the influence of complete anaesthesia. The obtaining of 
each quietude and non- resist a cce, the aboliiion of p^n, ibe mitigation 
of shock, and varimia other mivnntages afiectiiig both operator and 
paiieiii, from lhe judicious u^e of chloroform, have been already fully 
oonwidercd,* and on that mibjcct it is not neccsparr again to enlarge- 

The nectfifaty for un operation, in any case, having been clearly 
established, our object is Co perform it aa safely and expeditiously ta 
possible. The mere absence of protracted pam confers a tnost imixjr- 
lant advantage on the repamljvo powers of the sysiem; and^ so far, 
celerity is commendable, when chloroform is not employeiL But it is 
a very common an well as dangerous error, to suppoflo that excellence 
is alvrayfi commensitrnte with the rapidity of |terfonnjtnoe- In the 
gToalmai-rily of cases, haste is inc^impatihle with safety; while the 
latter is the jiaramount object in view. *' Ttito et celeriter" is the 
operators motto; but the '* tulo" precedes its accompnaiment. And 
now, mort! ihiin ever, basic and bnrry arc aUogeiher inexcusable. 
The student, aa an ojwrator, cliuiild loam to be rapid ; but rapid, 
because skilful ; and rapid only when safe. Ami, in some proecdmvs, 

• rriiicipk* uf Surgery. 



OPERATIONS. 5 

he will Dot fail to leom that attempted rapitlily mnat ever prove 
iDJnrions. 

Perhiips a more comioon, and still morp werious error is — the 
ima^iiiD!^ lliat ojji?ralii>us cuHalilute Ihp greal>?r and moru imporlant 
purt of Pmctical Snrgory. Tbo student ia Torj apt to be led nway by 
the mnre garisih and imposing ]iart*i of Ms jirofpssinn, t'^ thp. neglect of 
that which iH in Initli ly miicli the more valuable ; anil Iiq may also 
forget thai, in aflor life, ho will be only cccaHionally called upon to 
perform iLe greiiter itperatbnSr while daily he mast exert hia general 
kEiuwledge and skill, as well aa hia luirior h-mdieraiT, to avurt the 
Doces-Mty for thi; kalfc'a einploytnent. Ia the cast of a diaeaacd joint, 
fur example, he ia not at once to contemplate ampntation or reseclion. 
Such procedm^e is the ultimatnin, not the initiative of his art. Ixwal 
depletioo, rest, counter-irritfltiou duly timed and conducted, presFure, 
Bplinlfi, altentien to the general health, these — to some apparently a, 
sloipkT, hut in tnUh a far higher adaptatioJi of knowledge — conepire, 
and often with auccofls, not to matilftto tho framo and endanger life, 
but to Bave both life and linih, at little or no cost of elthf-r pain or 
danger. Again, in the fortiiring complaint of Btone in the bladder, it 
is doubtless a great matter to he able, hy a SfHiedj operation — severe, 
and perilouB to life though it be — to free the patient from his misery. 
And the accou:i[ilUhed tturgeon must, be nl all limes coui|>eteiit to 
undertake fearlofisly this ha?,ardoii8 work. But it is aurely a Kigfhor 
exercise of a beCler wkill, and both the meana and the rcsidt will prove 
infinitely mnre creditable and satisfactory, if, by the internal use of 
simple recnedie^s, and suitable attention ti.t hjgiene, the disease sltall be 
in it« very origin fmstrated, pain and danger dispelled, and health and 
comfort restoretl — all without the infliction of a scratch, or the low* of 
one drop of blood. In the caeo of iajwry, too, the purtunounl impor- 
tance of general treatment will be fonn<l equally to obtain. The sur- 
geon is ready at a moment's warning, lo amputate skilfully a crushed 
limb, which has obviously no chance of retaining iin vitality, and 
which, if not sjieei-lily removed, must inevitably |)erii the whole ft-ame's 
eiistouce; and when, by such Kcvcre ojjeration, hir BUoceedb in avert- 
ing the greater calamity, be has niiiKt just gi-oimd for eelf-gratula- 
tion, and may Inily wiy that a good thin^ has br^en done by lus art 
for suffering huaianity. But wheni in the case of an injury a shade 
less severe, there is a doubt whether or not the limb may he enabled 
to resist the threatened gangrene; when he hesitates not lo give to 
his patieat the b«aefit of that doubt; wheu, by great patience, care, 
and fitill, he arranges the raangbd fragmcnte in their proper place, 
retains them so by suitahle apparatus, aObr'iin? due support, and yet 
pennilling no undue pressure, regulating the play of the general cir- 
culation, controlling the efforts of ttie ins vitte — in short, averting both 
local an<l general disaaterj and bringing the healthful work of repair 
to complete, ihough it may be Blosrly, its valued process of cun^ and 




OrEItATlONS. 



vhen uUimQtoly a tborotigli and permanent ftnccesB crowns siicU patient 
and finiioufl IsibourB — siiroly thc^ cause for self-gratulwlion is inereaEed 
a him<]red fold ; the Kiirgeoti may well sav tint a far l>etter tiling lias 
been d<>ne b_v iiis arl ; and the diRcernmg' public will cot fail to nwiird 
a hlg-her arid truer meed of praise. 

The advftuce of surgery ^iU ever te fnnnd cbaracterised by a cur* 
respoi^diijg dei^reu^e of its operalioue, bfttli in amount and in scTerity^. 
The truQ oliject of our misaion is not to cut, but to ann. 

Sue on Itib subject, John bolf^ Ur^ Tivatl^e on .Surgciy ; uidtLc vorbiiti iiiudeni 
Turka on op^mtivi.' SurpJ^rj', more Mpetially thnae uf Lijslon, FtrtpidsnTi, ami Sluy. 



1 



^ 



CHAPTER JI. 

INJURIES OF THE SCALP. 



Bruite <if the Scalp, 

The Bcalp is especially ItaMo to severity of contaBion. It ia a part 
mncli uxpohod ta oxtcmal injury; U is Btretclied over dense resisting 
bone ; it is ;K>Sde«sed of very considerable vascularily ; and its artenal 
branches, l)ciiig iieilber iiiaciivo nor niimiU'i are apt to part wilh 
blood freely when torn. Hence, wlien extemftl violence is fijiplied, 
the hig^her reenlts of contnsinn aro very apt (o follow. TLe iulc^- 
menl mav give way; ranaing a contused wound, of greater or leas 
extent, wliose raargitts will ebtit^di and hepanUc, and whieh will not 
heal withont coiifiiderable sappiimlion, and a corrL'fi[jonding amonnl of 
alleniant JnflammjuiDn. Or ihe skiiii at first imbrnkcn, may slongh 
to A greater or Ii;aa extent ; cilLer immcdii\tely, fi'om tlie direct eflect 
of viutont contiifsbo ; or s^condai'Jly, by iDUuiuiuiitioii induced in a 
part whose vitility had been only lowered by the hmise, not aiuiiiii- 
lated' Or, tl^e iate^imenta remaining^ entire, blood h copiously 
eittravasaled from ruptured vessels; breaking np the areolar tissue, 
and producing a large tlnotiialiiig tumonr — f^oiuGtinies forming'- nipidly, 

wilh tetiaion of the ftkio, and mueh piiin in the part. Or, mil>t*(:q\icnt]y 
to pangiimpoiiB infiltrntioo, iiidiimnijilion mny bo lighled op in tJie 

implicated texture; inducing enppnration of an niifiivonrablo kind, 
with a considerable amount of conalitutional disturljance, and with a 
risk of tbe latter being unfavourably affected by tlie suppuration assiun- 
ing the asthenic, diffnso, and intiltrating character. The danger of 
BiKsh occurrences must Iw rcracmlicrci in tbc [irognosia. 

But the ordinary reBult of bniise, in this lucjilJty, in the formation 
of a bloody tumour ; blooti escaping more or less frtely from torn vea- 
*nd accwmulatinpf ifi tbe part; while room i» miide for its recep- 
a, partly by disruption of texture, partly by that which reniaine 
entire being pushed aside and cnnilensed. As already stated, tbe 
integiiTnent ib tenae or not, according i<i the rapidity and amount of 
extravasation. At tiwt, the indicatiriiis by tooidi are iinifnrm through- 
out the whtde Bweliint,^ all the blood l>eing as yet fluid ; and uniform 
fluctuation is more or less distinct, with elasticity. Soon^ however^ tbo 
blLMxl in part assuuies the solid firm ; and then the characters of tlie 
tumour change. At the circumfereaco, there is a hard, redsting rin^, 



8 BRUISE OF THE S04LP- 

more or less elevnfofl, oompnw^l of pongiiliiTti. Tn the rantre, the part 
isBoft, yielding, fluctuating; the extravivsalion there remflinms fluid, 
consisting chiefly of Berum, and situated immediately beneath the inte- 
gument* The clt>t occnpiea tbe margins. At thiB period, core is 
required in exuininalioii, ta&t n. false dSagnoftis be ajn\'ed at. Tbe 
fib^ri placed firmly on the cflnlre^ reudily dieplnceB iho ecroua fluidj 
ai;d may seem to peiielrate tci some depth ; wliile similar prefiauTe^ 
made at the marfjins, meets with hard, unyielding reeiatjince — and that 
at a conmderahly higher level than had just heen passed by tlio finger 
in pursuit of the relrealing sernm. Tbe careless observer of such 
things in iipt to imagine them unJouhtt-d indications of fruoture, with 
dcprcsstoDf having oconrrod in tho craniEim ; BiippoGing the hard ring 
to be the bf>ne in its normal position, with an abrupt broken margin, 
beneath whicb a detached portion hus been driven down. Attention 
to three or four circumstances, however, will mifEce to undeceive. 
The BymptomB of depressed cranium do not exist. Tress firmly on 
the Bolt and yielding centre; the Huhjuueui bone will be reached, by 
diepliHMMUcnt of the intervening fluid blood, and will bo foil firm. 
The hard rim of tho swelling will he foimd on a higher level than the 
general calvarium ; and, b^&ides, by a httle firmness of manipulationi 
if such be deemed necesaaryf the clot can be displaced somewhat, 
leaving tinn hone beneath. 

The tieatuieat of such a hmiso is conducted on the prineipleH 
genondly applicixhlo to this descripiion of injury. In certain Hitufltiona 
— an directly over known branches of the temporal or occipital arteries 
— fl^cUing may be in a great nieaauro prevented, by moderate pres- 
sure being steadily niaintaiucd on the cardiac aspect of the implicated 
vessel ; and this indication may ba farther fullilled, by continuous 
application of cold tti the part, aud its immediate vicinity. When the 
tnmour ha*' formed, even leusron will not ivarrant eithfr puncture or 
ineision ; for tbe adraisaion of ntmoepheric iuflnence to the cxtravasated 
blood, and infiltrated tijisne, is likely to induce inflaaimatinn nnder 
very unfavourable circumstances. By fomentation rather — associated, 
if need he, with restraining pressure on the arterial branch — let accom- 
nioilalion be oLttiined for the escaped fluid by a yi(:ldin^of the recipient 
texture; ward off inflammation hy general antiphlo^aticfi ; and await 
tho disappearance of swelling, gradual and tedioui though this be, by 
the natural procciis of absorption. The fluid portion of Lbo eitravaea- 
tioQ is lakeu up first; the coagulum follows, more tardily. 

But if in flam ma lion shall have occnrred, and suppuration formed, 
free aud direct iuci^^ion must uot he ^vlthheld. By no other means 
can diffuse suppuratinn be prevented, and constitutional dieordor checked. 
At once lay the part ireely opt^n ; turn out the L■oag^lllnn, and iiermit 
all fluids to cscapCp An unhealthy abscess remains for a time, but 
dulycbangGB, coutractfi, aud beals; and the knife ia not again requircd- 
But, delay incision ; and then tho knife ia calle<l for, not merely in the 



WOUNDS OF THK SCALf. 



fi 



trulaflj pfttt, "but in the pnHa ftdjuneiit, now llic eeat uf a spreading 
uihenic inflajnmaluiiij and in inimini^nt danger uf pensliing thereby. 
Tbe asllienic tendency, as formerly hinted, is pruljtLl>ly owing to the 
bruise linving lowered the vitality of the parts; bo impairing thdr 
tolerance of the infljimmrttory procesB, 

CouBtltiilioual manaj^'ument is Qot to be JieglecteU, It isobvionaly 
of great importance lo iivcit, or at Icftst to modentt*?, the acceswon of 
An inflftmnjrtb^ry process in the injured part. On this ^onrd alone, 
rest nml quielnde, aritiphlogifitic rf^mt^nf and T>erhnpB depletion, are 
esjwdieiiL But the necessity for recourse Lo sncK preeantionH becotnea 
still more appArent, ;^hen it is remembered tliat the brain, in all ca&ea 
of severe bruiiie of iho scalp, must have suffered more or lean by con- 
caasioD, and has to bo pi-ok'ctcd from the conaequenr^cts. 

When all rij<k of iTifliunmntory accflRRiiTn has pflssed, snd swelling 
has not yet disappeared, absorption may be hastened by JiBcntient 
meaGnres. The part may l)e kept wet wilb a eohition of tbe innriale 
of ammonia or with a weak dilution in water uf the tincture of arnica ; 
afterwards friction may L^e ut^eUf and, if ntfvd be, pressure. 

liloody tumours, of tbc furcgojiig nature, not uufrequently form 
on the prosentintr pnrts of the heads of children, newly bom ^ eapecially 
if the labour have been tedious, or the pains very violent.* 



* 



Wounds of the Scalp. 

Simple mciacd irotirtda of the s(?alp are apt to prove tronblesomo by 
bleeding. The arterial point or points are to be ox[)oBed, and secured 
by ligature. Pressure may, in some bstances, succeed ; but, Jn 
general, it is decidedly inferior to the nso of ligature ; being not only 
IcHS cenairi as a hemobtaLLL', hut also liable to induce liloughbg, or at 
least a tronblcBoinc ulceration in tho comprcEEed part. When necoe- 
sary, therefore, tlie Rurgi-on need nrt hesitate to extend the wound, to 
facilitate accurate deli^tion. When hleeding has been arrested, tbe 
wound is lo Le brought to^^elher, and reUnined in apposition; but 
ButnrcB_ ar e, if puasibic, to be avoided ; experience having siiown that 
tare they are^eBpec: ally liable to prove tbe exciting cause of erysipelas- 
The Valfflcquent mana^ment ia bqcL as is onlinarily adopted for 
securing adheaion- One simple precnntion should nt-ver lie onutted at 
tbe commencement of tbe tieatment ; namely, the shaving of the 






• Thi* flffecliun h ti^-i^fll^d by <il>9ittricifln» Crphalhatnatoma ; while simple blfHxly 
kolUtmLlun uf Lbt pni^'iiliTi^ [mrt uf iho rH.'Hlp In Uimitil Uif capttt Koccaluncttm. Id the 
CDintnnnc^t hnn of Cijpballifl^tDndiina, iJie PutiptricroiLlal, tfai; Lumoar bocomcB mr- 
nunded &t Uie liofu: Ly au ojjseous tiui;, nnil the poricrnuiiim, [on, ia iHinLctinioii ttio eeat 
or oweiiui dejioaii, so aa lo be felt trackliug over Lne funUincd Uhm\. Thifl Hood tUmp- 
peoring, th« oiriificil pflriiTaDliim nppriPfii-hoj the bone, and iiiiEtua witL it» rough uid 
barfl Jiurfufl, causing aLighL (tuckeaisg of the t>onfl al that part. 




-TD 



(fu l^zJU 4 liA>^ ii%XU<UT)'^i^Cj UaA<^ ^'^ ^'' 



II 



WOUNDS OF THE SCALP. 



Bcalfs !iol only Ht tho wmtnded jiart, bul to Bome (lifitance arotrnd, 
Tlie retentive wtraps^ nml othtr drtsaingB, arc tlien more rea*lily and 
eei^urely upjilieJ j llie pail h more certainly kept free from irrilalion ; 
CDoLn4?5S IB more eaeily molntutiuHl ; atiil innpectioit of the wDnsd'n 
propfreeft is inon* complete. 

In Cfiniused and lacerated icanndi, ihere is flic mme Hak of nofa- 
vourublc iiiflnmmatwiii as in bruiBe ; Rn(] this is, nocoirlingly, to W 
giiardt^il Bguinet. Vt-ry ofloH, the ^vouml \s extensive^ ani irregular 
in fijrm ; a iKrlioii vS the sculp is dtlaehetl from tlie :*ul)jjicont lione, 
and linnga ov€r, im nnBccinly fljvp. Fiknncrlj, it was tbc enstoni to 
cut ttWfty llie pi»ndnlijns innrtion ; it l>eiiig eonnifloreil tncftimble of 
re-atlachnieril. Now, iL is invarioblyprpserved, ainl cartful I y replaced. 
IL ttflilom sloiigbe, even in parL E<pany scHoro, bowcver, will iL 





ngi. 



Fit!, 2- 



iinite At one? by adh^Fiinn. Tt niippntnitoR, grfLnnlntes, and becomes 
fllowly, yet firnily and Falisraulorily, rejoined to ibe snbjaccnt parts. 
-WLen A coijge^led and llabby btate of Ibe flap occurs^ as often happens, 

rifi, K TliP CouvfC-cbL*f; ft himdk«rclutir » arran^^l bh to irowr chL' hcnd, witli ■ 
vi<?H to nfjiid dividing. Th*- Lnndki-rdiipf liflvlnffl*pn f'»l<lt'diiitoairiun)iiiljir?l]fl]K',lbe 
oentre "f iIip l-ow !* plni&J on tiie rpnireuf ilip roreln'ad^ tlw iHbdy u(\ht bandkfrcbief 
mverinf; like hbi J^ ""'' tto •pcx or rnriKT li^iuf^ijiif; ditwii rlit nrck. Tliv iwu 1*h»l' Fuda, 
prPTioiiflh' lyjn): "O iLie rhrck^ *ro ctoakiI tviic-alli ihe fcoipui, L'uvi-rinL: *' ibc uyvx or 
rurnrr* And are Im^ught fnrhard duil liiil cm ilic fnri'liftjd. Tlie limulki'Tcliief i^ iIk'D 
MiiinpLliiHl liy pulling tht " np*x or totn.-r,' v|i»'li It f iimctL oTtt idv iTUi^arU 'ViiaE,''iin(l 

F^. 3. A dduWC'btrtJtfil r>l|f r, apptied m> A^ to cOT^^ tlio headi mdtini: cqiuble 
prwsuTfl «i BTt'jy |Ktliil. Tlio imlre vt llic r*>ller in pWcii low iJuwn ut ihc forpbi'mJ, 
uid the two hojiilfl irt wrriiJ li*ck unil moile ^^ cri»n luw d"wii t«innih ili{« nroi|»nt- 
Onfl btiid i» llirti bmi^bl ovtr ibn- vortos, wluk^ Uk nthur b carrii^ liarij'itiliny round 
ixi Up \^ extremily ; and LbU, mnu'd up over ll»e l»-<riMnifcl uui', la canicil »i£ut Ui Ibe 
ocpiput, "lifll^dv cviTlflppiiip the ftirnier vi-rti*'Al bniid. Al Ihp <KTi]iiii, tlip ln.inl, nro 
a^rt iTfM*il ( tb? suri^euii flbiftiiii: bmnUl, nnd a third tiim l* iiuidu nn iL^ olJur tide ar 
Uie ^-rrtii'Al Irnid, nlult a Uiird bnrizimiAl piiud BecarM it *♦ btrwrv.. And Uiis in coti- 
liBiwd "intii t^i^ «l»ol* head hu bwn unifr-raily invealwL — 4/**'" i^rmdrtlt. 



WOUWDS tJF THE SCALr. 



11 



during tlie sTu^puration, support by carefally ftppKed bnnUftging Is 
highly expetlienl. 

For relainiTig dressiiigg, nnd affiji-din^ s^iitlc support ti> the scalp, 
a common liamlkeriihief may Ix? applied, a^ in Fig. 1. 

But when direct, accuralv^ and considerable prcsaure la required, 
the double-headed roller is prvfernble, as in Fig. 2, 

For ret-ainiiig dressings oa any pflrliciiliir part of the hoadj the 
four-tailed bandage is often very nftef"i/fts in Fig. 3- 

Vot unfreqacntly, the bone is rndely demided of all its 5o£t icvesU 
menls; as in heavy falls, when the hejid comes violently in contact 
with stone^ The fiericranium is mbljed off, and the bone is not only 
wholly exposed^ but roughened in its own texiuro. In such caavs, 
wc are not to refrain frcni re-ndjuBting ibc soft parts, in the Iwlief that 
eKfoliation ntriRt ne^e»nari]y f^uHiie, and that 
an open condition of the woniwl is conse- 
qnently to be desired. Many booea thus 
circumstflncei.I recover entirely. They may, 
for a day or two, become white and dry 
on tbei/ mere surface^ as if undergoing necro- 
sis there ; yet it ia W Do means iitiu<'ii:d 

— when sncli necrosis is n<d favoured by 
Ifie treatment employed — to find this diy 
hoTie revive, Incoming vascular, brown, and 
exhftlent, as before, and in dne time conln- 
buting ita quota to ihe general procesi i>f re- 
paration, Shoidd inflaniTnatjon supervene, 
and advance to suppuration, cither in (he ^^ 

limited or in the diffuse form, early iuci^^on 

is demanded ; in the one caee, to evacuate pns, and prevent accu- 
muktion ; in the other, to limit its formation and prevent infiUra- 
tioUh When the areolar liaaue beneath thu occipito- frontal is' expiuiBion 
is implicated in tht? latter event, ineiaon is required lo l-e teptcially 
early and free; not only to avert destruction to texture, bnt also tu 
prevent, or moilcrale, implication of the aU inn>ortant cranial contents. 
These, indeed, must be duly regarded, throughout the whole period of 
treatment, as in simple contusion. 

Puiichtrcd uounds of tLe tc^ilp* iiaually oblique and j>enetratiiig, 
ivre always itnikirtjint ; being very apt to be fuUowtd bv Bcverc irifliun- 
ination; and at an early period, and on tLis account, demanding inci- 
aionn As a general rule, it may be stated that the inSaramatory process 
in the st^alp must always be treated with great activity. First, because 




Fi^. A^ The rour-Iai|«I bAndo^t ; of UAC in rolAining iLnwdmi;:^ r»ii njiy partkiilM' parL 
"f Ibc hold. A iiivcp of ctotb eiMt at oilhcr end : tin- rFnlral iinsplit portinn \ihcvd on 
lIio drewiny- Tho tva pijslerior ewla ^--ourpd l«low the «hin - iho twti »nlcritf cnita, 
ijviirlflppbig tlHtow, iTosw a[ ilic (Hxiput, uid arc bIao Bocured betoT U» i:ldJL—Aj}rr 





12 



WOUNDS OF THE TEHPOItAL ARTETtr, 



the textures are unfavoumblQ for Bafe fld^^arcemenl of tlie proceaa^ 
tLey are vascular, tense, unyielding-, fiLroua; the affection Ja npt to "be 
acute ; the esudatinn is capions aiid rapid, accommoilation afforded by 
the recipient lexture is lOi^ufficicntf tensiou ensues und, as usual, 
aggravation follows thereon ; suppuration is siieedy, and apt to I© 
diffuse ; and the pua tends to buiTow rapidly, and in nil rci^pc'cta da* 
atructively, hetiealh the fibrous BtnictiireB. Secondly, the part affected is 
iji close and dangt^rouB proximity to the crania! contents; aud these 
are apt to be involved in a Gecondary, but not less important, diBcase. 



Wounds of the Temporal ArUrj/. 

Arttriotomy. — Under certain cireutnetanees il is deemed adviaabl© 
to abstract blood, with a remedial object in view, from an nrtiTy, and 
from one Bituale in the upi)cr pari of the body. The anterior branch 
of the temporal artery is usually selected. Being qitilo subcutaneoua, 
it is of easy access ; and, being also placed immediately over resisting 
bone, it is favourably situttlcd for hciiiortlalic puq)uses, A euitjible 
piirt of llio vcfwtl having- boon fixed upon, it ie eteaditd by the Gugere 
of the left hand, while & lancet, moved by those of the right, is made 
to perforate the arterial tnbt-, in an obliquely transverse direction* 
The entrance and exit of the lancet are managed so as to make the 
wound of the integument considerably larger than that in the arterial 
coals ; in order that there may be no ob- 
slruofiou to the free OEcape of blood. A. 
section of ihe wound, in fact, should resemble 
that of a cone ; the truncated apex corres- 
ponding to the aperture in the vcBsel, the 
base to that in the integument. When a 
sufficiency of blood has floweil, it Je well to 
roititroduce the lanect, and to move its point 
Ro SB to efleet eomplele sedioTi of the vessel; 
in order that contraction and retraction of 
eaeh orilJce may lake place, and natural 
hemoRtnlics may so be favoured. A gra- 
duated compress is accurately ai»plied over 
^' ' the wound, and retained by a l^indago. 

The dreflfiing should not be disturbed fur several days. 

If blood do not escaf* readily enough, a cupping glass tiliould be 
applied; care being' taken to raise the rim gcntiy over the artery on 
its cardiac aspect, otherwise the pressure must inevitably arrest the 
flow. Aud this is the only mode of uuJ^p»]g >vbii:h i:an be toiisiJered 
warrantable in this aituation. Ui?e of the ordinary fiearifieiitor here 
leaves a very unseemly scar, especially in the female. The lancet's 
punclure in arleriotomy is, on the contrary, slight, and its soar Hcarcely 

Fig. 4, l^iuprcn applied Co the tcmporjil irtftry, aE\er ortoHotomy. 





WOUSDS OF THE TEMPOBAt ARTERY, 13 

ipfnccisblc ; tsiA^ «t the same timt^, it is to be remembered, thftt from 
thiE one pnnctnie blood will flow miicb more freely than from tW the 
twelve JDciaoDS of the ordinary instrnraent, if only skin-deep. 

In accidental woimds of the temporal artery, deligution is generally 
preferable to preftsnre, aa already Htated. In the case of a more 
branch, it may be BufBcient to tie the cardinc orifice. But when the 
main trnnk is implicated, the distal orifice must also be Bccnred, other* 
wise recurrence of hemorrhage is almost certain. 

UnpUasarU eonteqitenctt sometimes follow wounds of the temporal 
Vierj, whether accidental or intended. FaUt an^urUm may form. 
This, Qsnally, has attained to hut a small size, ere the patient's atten- 
tion is arrested by it, and the surgeon's aid B'>uglit. In llie majority 
of caaefl, it is sufficient to put in force the ordioAry treatment far recent 
&be aneurism; to cut through the tumour, turn out the clot, and 
secure the vessel by ligature above and below the wounded point. In 
those cases to which such procedure may seem inapplicable^ removal 
of the small swelling, by two elliplical incisions, may be had recourse 
to; securing each of the blefding points in the ordinary way, and 
bringing the wound together for adhesion. 

On removing the compress, after arleriotomy, the wound may bo 
fbnnd to have degenerated into u/c^r. The ulceration Bpreads, the 
venel is opened, hemorrhage occurs; and, by repetition, the loss of 
blood becomes hazardous. Pressure, reap])lied, may tcmiwrarily arrest 
the flow; but necessarily favours the advance of ulceratiun, and so 
renders return of the bleeding cftrtain, on removal or change of the 
dressing. It is better to abstain from pressure ; and to tie the artery 
on ea^h aspect of the sore ; either by regubr dissectimi in the line of 
the vessel; or, when swelling and condennaUon of texture rendc^r that 
difficult, by IrauHveifle wounds — securing the bleeding points by 
forceps in the ordinary way. Or, if the ulcer be minute, excbion of 
the changed part may be effected, as for false aneurism. 

la coDnezion with this Chftpter, consult the ordiiuuy oulhorltid in SyBtemntLc 
Sargery. 



*^ i& 



-lA^-vO*. ^MA^C^tXcLUj 0«£Xt^,d 






CHAPTER III. 

INJUKIES OF THE CRANrUM; AND THEIR 

CONSEQUENCES. 

By external violence t]je cranium may be eliflken, fipsureJ, or frac- 
tured with coniniimition. In any ca^e, m^re or leas injury is at the 
E&nic lime sustmDi^ by llit craiiiul coutciitfi. The braiii and jIh 
invealing mcitiljxu^ii'H laiiy Iw turn, nml Itlootl iii.iy beotime extru- 

vftHJtled Th^ itiflii minatory protesN may l>e kiiMJlvd, iieriillng life by 
eKu<latiuii, eu|ipiiralion» or chronic cbiiii*^ of slnicture. Or [lie brun 
may be merely j^li;ikeu, and ttsmjHirarily iaipairi'd in its fuf)4:tian. 

CcmaiBsion qf the Bram^ 

In Rlrict aocpphilion, llii^ tt-rm cbnolcK a men? sh^ikiTio: cif the 
organ; ^viLhollt oTiy appreciable lesion of stnicture* and conseqweiit 
escape of UcTod, imiDediale or sctiondary. Ftjnction is impaired, oflert 
most fierioiisly; UBiiully it is afrcr a lime restored, more or leas coai- 
pleiely ; yet not wiilmut nniLh risk of m\ Inflaniujaiory process inier- 
vening^ in either the hrain or iiM nn-mbriLncia, to ixiodifj", prolmct, or 
prevent the fitrtnnate issiip. Undf-r the itzipulse of n hlow- or full, the 
braiij must sustain nioro or less viLrution, if the cranium rem;iin entire. 
it is *'a pulpy organ, wldcli exactly fiilw a nearly Kpherioal bi>ny 
cavity, n huse pariettK are elastic in a coneiJerable though very variable 
degree; atid if thesu parimes sustain any sudden c^hAUge cf Abape, 

tbcir euntetilB nitit^t ^u^tain a cDzTesp'Hiilln^ uuioiiat of cumprceainn. 
Ab any nllernliim in the hibfljie of il splieneiil cttvily must k-sten its 

aipacilTj whenever anj external forte impiriijes on the crauiura with 
suRieicrt violence, it must be fliittened rit ilie point of inipiict, and ei- 
pamied in eomo opposite direction; but thtse changes are, in virtue 
of tbe very cause ivhcnee tliey originate, of but momentary durnlioQ ; 
the poiiil priuiariiy flattened by tbe compre&hing force immediately 
n?wiineB its originiil phsip?, which is npRpssiiiitv fnllnwed by a eurres- 
pjmlijig return of the expanded portion of the eranium to its previous 
dimensions. These oscillatiofia may occur several limes in rapid suc- 
cosnion, their nnudwr Jind eilciit depending on the elasiiciiy of the 
crmiium, and on Ibe amount and direction of the foree applied. In 
cuncnBEJon, then, the entire brain anatiiina a eoriea of vibrutiooa and 






C0HCDS3IOS. 



tnomontfiry compTVPsionRf vjiryin» Iti nnmber Aud unount m every 
ima^fia-Lle Jef^ree iei Jiflereiit casch." * 

The force may bo ajiplieil eitlier directly or indirectly ; tbe cranium 
TBAy be ibe pAft Btrnck ; or tlie patient, alighting' on his feet or nates, 
may hare concnssion conveyed to tbe cHlvarinm through tli« sjiinal 
column. 

TUifl vilirfttion of the brain, uHl.li disturbance of its circiilallon, and 
jierhiips tcnji«riiry condensation of ita Hnlistance, is attended with 
symptoms of marked disorder in the orgmi's functions. Sensation, 
mental power, and voluntary motion are more or leas disinrbed ; and 
a depreshinrr effect is exerted on the general circnlation. The pftlient, 

Stuimcl, nnd imri^ or less in^iitdbUf lit8 TuottunWh^ J^ak-t and culd. 
Tnaenftibillly^ howevcf^ after it time, is found not t'> !« coiniilefe tx^ept 
in extreme canes; by loud callln;;, monosyllabic ackiiowlcd^nent may 
be obtained; by pinching the skin, or otlifrwise causinj^ pain, some 
evidence is uf^nally given of {min Itciug' felt, aod an attempt in made 
br the padentto move tbe part from the Hupposcd Bourct: of injury. 
Power of motion is depressed and l&t(?xiti niFt dcHtn^ycd ; and tho 
Tolontary musrles though ndaxizdi are ttot tnily panity^^ed- Ilet;|>ira- 
tion IB feeble, slow, and Hig'hinE'. The puW Is rapiJ» wnall and flut- 
tering ; and especially weak at the extremiliee. The pupils are usually 
contracted, and insL-neible to li^hl; but their Ktalo is viiri;ible; some- 
times one is CDDtracted, wLilc the other is either natural or diluted. 
Squititing is aot nncotnmoiK Vomiting i& oflett prcMjut; rather of 
fiivourable porient than otberwisc — premonitory of recovery from this 
bU1« of depre^ioTi- 

The patient beeomes more easily amused ; and responds more dis- 
tinctly to interrogation, eilher by w&rdw or by gesture. Kespiratinn 
becomes mr>re full and com[>ose<i. The pulse in lese frequent, and 
more distinct f bnl., at this time, (Ijq clreuliLEinn !•} jjccidlarly irnlahle, 
the mere effort of change of posture usually inducing maiUed int-reaae 
m the ftegutucy of tiie heart'^ action — or evGii syrieoj*. Pain now 
18 more ftlt by tlio patient; and is referred to the head, Votuiting 
may coutinite. The retnrning mental power is apt to prove errant 
and deceptive. 

Not unftetjucully, a slate rebembllng s^maiLoibulitim coutiuues fi^r 
aoin© houra during tlio traimitii^n to recovery. Mutiun, sciiMitiun^ soioe 
of the Epccial semtos, and nincb of mental power, seem to be restored, 
yet the patient remtiins a.^ if in a deep nleep- He may ribo, nash, 
shave, dresa, ^fe ram bo late ; all the whilt? nuconsciouH. 

But reaction seldom stops at mere restoration of the normal stale ; 
Ihe houadary of liuallh i» crossed, iji an oppohite direction, Reaction 
proves PXccBsive ; aed ByniptotnK are evinced uf an iiiflaniinatoi'}' pi^j- 
cess begrnu in tbe injured part — the brain, ita membranos, ur both, 

* BrUUIi nnil Fortiyit Af*<lical iTirieto, No. 30, p- 1G3- 8« nUo W- Gav a'& Fjperi- 
mtnU oa this Aubje<;(, 7\-riiti */tt Ftaiet 'U Jife^ p. 1>n. 




18 coscvssiox. 

Tbe pdw bnttnev fall uid hmrl; the Ekin hot «Dd drj; the fic« 
fioshed : the «t^$ blo^d^ol : the pupils iDorr coDtracted ukd inseHEaible 
to light. FaL;i, great and mcreafiin^, is complained of in the head; 
Tvstle^ness is more and more marked : the mind, which may hare id 
great me^f^ire rpcovered, a^n loses its Leaiibfol balance; delmnm 
£T]»'rveBe$: and so the s^raptoms adi'ance. Resolution may occor. 
Or cff':don acenmv.Iatef ; coma a iniluced ; and the issne may be &tal, 

Praoiioallv. concoifioti mar be dii-ided into three stagea. 1. De^ 
pres^on: tn&rked bj tnsensibiliiy. and feeble cLrctdatioD. This may 
be intense and endnring ; proving latal and that speedily — the patient 
quite unconfcioas ihroughout. 2, Reaction. Tbe symptoms of de- 
pr^fSLon (Ckss oit: circulation is restored : and cerebral function returns. 
In tbe slighter examples of iujury, there may be no further prt^ren 
made trntowardly. Reaction does not prove exce^ve. The head is 
confused and giddy for a day or two; bat the pulse remains quiet; 
and, within a few days more, all has passed off in safety. 3. Exces- 
sive reaction. The inflammatory symptoms set in, and a state oppodte 
to that of depre^ion is esl^blished ; all is excitement and perversion, 
both in the general circulation, ai^ in the functions of the brain; and 
life is brought into imminent Jeopardy, by phrenitis, or mencngitis, and 
by proi>ortioDaie iuflammatory fever. 

Trtatinent — Thia necessarily varies according to the severitj of 
the injury ami the inteni<ity of its results; but more especially is it 
difierent at different periiHls of the case. A man stunned by a blow 
or fall, and labouring nnder simple concussion, is oflen bled on the 
instant — or an attempt, at least, is made to bleed him — by the rash 
and thoughtless practitioner. In other nords, a fresh and powerfnl 
ageot of depn^ssion is exerted on the geiteral circulation, when such 
depnession is already great, and has probably brought life to the very 
verge of extinction. If blood flow from the wotmd in venesection^ 
under such circumstances, perhajifi life is lost : at all events, the direct 
nntowanl rcsiUt of the injury is ai^ravated; and the case is rendered 
both more urgent and more protracted than il otherwise would have 
been. The lancet is certiuuly not to be used, during this stage. In 
uiauv oases we should W liiilc more than passive sjtectators. The dc 
pr*.'5sion is not extreme, uor giving indications of long continuance ; 
tiiTus of reliction, on the contrary, are slowly manifesting tbemsolvea ; 
arid we await the natural pr^^gn'ss of events. Not altogether idle, 
hv'xvwor. Although ni.>l engageil in nclive treatment, wo are prepared 
toravuviry. tthon oireunisU'vuci's shall cull for our intcrfcrt'uce. The 
pat:.'iLt is s:rii*|ysl and put to bed. His whole body i*" carefully exa- 
miut vl. Ho oauctv't tell us whether or not other parts have l»ccu injured. 
K>:'^'> an au\vous iuvo*tii;atiou as to the exiatciKv or not of internal 
iuj^::\'v, HO tuust \\iT\*fnlly examine each joint aud K*uo: deloi':ing 
fiAiMitv ov *U>UvA;iou, ai^l having il iuimedialely ^vtitii>l. while cir 
eu^uM*u^^** atv a-l »* jyvuliarly tavvmrable for the tv*;;".iTx>d mauipuU- 



TUEATMEKT OF COSCUBWlON. 



n 



tions. On recovering' his senses, he has not tc compljiiu of a. pauifiil 
aiid distorted Knii), now for tlte first time ubsened; hut fiitils ^^hikt 
was distorted <liilj replaced, and dready sume wjiy iidvanced in the 
prucepH of TL'pair. The head is camfiilly shaved ; and is phiCL^l un }>il- 
lowB, (."onHidcrnljly dcvaleil. If woiuid yf llie Hcalp tiial, houiurrhage in 
anveled, if need be ; and npproxrmfiliun h eflecttd in tho onlinary way. 

Shoidd llie depres-^iiin provL- grr^at nud <'Drtiniied, |ilainly indit^at- 
io^ nuk to life by syncope, something nrnre is rw|uiiTd of the practi' 
tioner- He endenvoura gently to on'^inale reiicliuo, Wanntb U 
applied to tlio Rurfaoe ; and friction is nsvd over tUe cbeet and abdomen. 
If Lhia be not sufficient to turn the course of the symptoiLs, a Blimulont 
enemn of tuqitntJiie ia given. If slill ihe prognjf* be dnwnwuvde, an 
atlenipt is ma<le to ci^nvey to the ftlomflfh some warm l^a, or Ri>np, 
or witie iind water; and stinmlantfl are held lu the ntislrila, fur insuffla- 
tion, Tliese lust, however, are always to he warily managed, so bh to 
avoiil risk of injnry by ilieir too frea application to a pabetit at ihu 
time insf^nsible of [i^in ; and the giving of Qiddu by the month, loo, 
must be effccti^d with care, Icpt they pnsB into the nir-paffiugesj imd 
produce uHpiiyxia- So S'^on e.'i reaelion ]itis hf^^in, we a^asa from our 
auxiliary efforts; and jigdn become passive onlookers; completion of 
the secoTid Btage being always safi'at in flie lianda uf Nature. 

if stiuinlaiitfi are ns^d at all iulenially, it must be only in urgent 
circn instances, and witli much caution ; t)egun with a qtariDg liand, 
and repented warily. Anil, in general, we are well content to do 
nothing, in tLia way ; knowing that moderate depri-nfiion w n favonr- 
ftble occiirreiice ; nnd that iireuiatnre cesi^ation of it, especially when 
followed by nhnipt and marked reaction, is apt to prove most injnriouB, 
For, at first, we can never he certiiin that tlic case ifl r>ne of pnre con- 
coRsion, Tliere iniiy be a lesion, by laceration, of iLe hraiu's suhMance. 
Duriri;^ the cxiflttnce of concusaicfn'o first stu^, the caea tetnmne^— 
prBctiiinlly — one of corjcnHsion still ; circnlntion ia weak in the torn 
part, as elsewliere; eitravaeatinn of blood does not take place from 
the oj-en veasele ; valuiible opportunity a afibrded for their closure by 
uatoral hemostatics; and when at lant — it may be after a couBidcrahle 
numl>er of hours — the natural reacticn eUiwIy sets in, and cirt-nlalion 
ia proportion latdy rcftlorcd, fititl no e9cai>e of hlood occurs; nnd the 
tiyniptotDs mny remain thi>$B of mere conenfision to the last. Wheteaa, 
had the period of depresaon been abridged, and reaction rendered not 
only premature, hat aleo abrupt and active, circulation would have 
been resti^rcd in the iujnred part ere the open vewds had closed, blood 
would have been exlravasated, nnd compression of the brain must have 
enfiiied. Or, cren if no lewion of the hiaia have ^'ccuired, the easy 
beioj^ in all respects one of mere concui^Hioiij still premnture nnd 
excessive resictiim is most huzardona; by tendinfj; not only to kiudlc 
au inflammatory process in the brajn or ita nicmbranep, hut riUo to 
secure its being of an aggravated and perhaps uncoiitndluble character. 




18 TUEATMENT OF COStlUaSlU^■. 

Thatt, then, it h plain that twu ^cat eirurs iiiajr Lv irummjIteJ In 
the trcatjm?nt of the Ci-^t etage of i:uDcii>?aon. BlfjoJ mny be drawn 
liremntnit'ly ; lowering the vittil powers still furllier; uii necessarily, 
imtowiir<lIyT perJiu[)K ffttally. Or stimuli may ha iiiipruil4;ntly em- 
liloyed; loo wwtIj aud Uio freely; liurryiiig uii n^ action ; and eJidan- 
gering life, either by comfiressioii iu consoqiiencti of extravasation of 
blooilf ur by an LufliLULUintfiry procoa:^ of nti iirgi^ut ajid miUiward 
charaotor. Lot both erroi-e be fatiijiinisly « voided ; for tacb ip of a 
iiKiEt grave nature. Wliile we take care that the deiirewsion does not 
proceed too far, let us beware of doiii^ anylbiiig to c^vA eilber a 
premature or an cxcesfiivf ryacti^/n. And wbeu we alleujpt to fulfil 
the former indicaiioD, lot us beware botb of inducing aspliyxijv, by the 
miaconducting of ingesta ; and <^f ujiusijig^ Lroublct^oiue excuriatlua and 
HubK-quent inflammation in fliiECe]itiblo ilhJ imjKtrtant parts, by the 
spilling of irritant slitnuH iiL>on them. 

In the fiocoiid stagt', while reaction is in progress, we have either 
band ready — to favciur, f>r to rojiresa— yet very often fiiul it prndeni 
to abstain from active interference ; leaving the task, almost entirely, 
ill the more skilfnl and i:oiDpi'teut hands of NuLure^ Wb content 
onrselvcH with carefully excluding all Bonrce of ejicitcmeat, eillior to 
tJie general tirctilation, or to the brain's fimetion — more especially 
light and noiK! ; and coM is oontinuouhly applieil to the ?iUaven scalp, 
by wclLcd chjths, or by evaporating lotions. Such treatuieut is not 
calculated eiiber to thirart or to prevent tlie normal umount and form 
of iijucuor: ; wltile, at the ^ame limi*, JL leans to the sldu n£ r^pivr^csion 
Bufficiciitiy, to gward tvgaiast tbo excess cjf reaction which nut imjtro- 
bably ia s[hee<1ily to ihrcuten. 

It may bapi^eu that though the reactive effort la well begun, it 
ceases, fla^^^fl, and ivtro^rades^ a jitriud ti dt'iiression again sclfi in ; 
and thic* rclajwe louts inori! fonnidahle than did the tirel elFect of the 
mjnry. Vnder such circunmta.rices we are no lojiger inautivu H|)ecTa- 
tuiTA', but cummijncu a cautiuuff ayatem of stimidalion, ab formerly ex- 
plained. If, on Ihe other hand — as more fre<jii*"»itly ha|i[>eiift^ — ^reaction 
ihreAteDb to prove bulb " fast and fiinoiis,'' we interp'^si^ *'"r rcproasin^ 
ageiicy. We em[>ty the bowela by the eshibituin of an aperieiil enema ; 
and aij thi>J, by the naore leisurely working of an internal jmr^'e. 
^eehuiion from li^ht and noise, vlevaiioii of the head, and continmui^ 
apphciition of cold, arc juost carefidly maintained. And if atiU the 
flclion if* filliLTiio and in exceai, we pn?X'a3'<i to iibtaln a *?tluiive result 
by blood-lettiijg. 

In tlic third etaye, when reaction ia plainly in excesB, and inflam- 
matory symptoms are fa.^t developing theiE .selves, the treatment in 
lEecidedjy and aeiively antiphlogistic. Quieturle and soclnnion are 
fnore Hlriotly tufi*iccd ihau e^er; it being idl impovtAut Ut obtain rc^l 
iff the organ uiTcct^'d, an cnijiletirly a^ circnmKtaiit'ea will jit^rmit. 
Bluod is taken from both the Kytilcm and the part ; by vejjescrlion or 



TBEATMENT OF CONCLf&HlON-- 



1« 



n 



srterTotoiny, and hy 1e(.H:liin^. Asd Biicb depletion ih re|>e4L6d a£ oft 
and as freely us cirtiiruslances seem to Jamaiid. rurgilivca are 
ttCtivi^iy udniLnbtGrGd ; aiit] it la well lo renieiiil>cr that in inliamum- 
lury Hftuctiotia of tlic craniiil conlcula, i'e[>eciiJly pijwcrfid dosca arc 
reqnir^'d. AnlSjtioiiy^ i^r ncmiilp may he given. But when the sid)- 
Btuucc of the hrnm is plaicdy irrdiealed ati tW site of the creEceiU 
inilAniiTJAiory proccBS, ne do not heaitaite to place tbe aystem rapidly 
under the infloL-nce uf mproury ; having fidl warrant for this in the 
delicacy of sinicmre and importance of function which art involved, 
Caloujel \i ^vcn in amaW tlont^Aj frcqiiecilly repealed ; and, itaiially, it 
IB nc-itlior necossary nor expedient to ciimtiue it willx opium. Not 
uecef^saryf for tbere is a ahiggiahncsH of action in the inlcstinal (Muial, 
engendered by Uio disease, and coneenuently but littl« rihk of the 
mineral proving purgative; and not e:([>edit'nt, lest we endanger the 
productioa of n&rcoLtsai, and conuequenL determination of blood to the 
part a/lbctcd. 

Sometimes deliriiinij with eoiiviilsive movements, cruilmu^a aller 
fiili bleeding, and is aggravated by its further repetiliim. In such 
circumstances, the pulse and other cbaracterisiics of nervoua reaction 
will Iw found J and relief will follow the exbihilion of opium, guarded 
by antituoiiy. In Ihe ao I Ipb logistic munagemeul of advanced cases of 
injury of the heu^^ the ocourrenoo of ^:ou^rnlbionfi is by no nicaEis 1<i be 
conatrb^n^d as BunicJont warmnt for conlinnanco and pushing of ihu 
antiphlogifilii^H — espeebdly bloihl-letting; ; fur, often, ibcy are I'uund to 
be of an asthenic, or purely nervous character; aggravated by antl- 
phb>giaticfi, allevlaled and elected by amendment of diet, and cautioiia 
exLibilton of opinui. 

Tlic brain and mcmbrauea, having recovered from the inflamma- 
tory prot'CBB, remum hiii^ nealc, and reqiiiro *lill [l wnlchfiil aad 

patient cure, i.it^bt and noise mu^t not be soon or abruptly ailmitted, 
Conversation, rt^iding, thought, or other exercise of the mental powers 
must be diMconra;^i^d. Eve[i tbe fnuctions of special sense should be 
beld in comparative abeyance. The head is shaved, elevated, and 
kept cold. Food \p> tparin^ and non-btjiuidaut. The Im^wcIs oie kept 
freely moving. 

If rcHohilion rTo not oceur, effusion takes place; comprehsion of 
the brain supervenes on the eoncUBsion ; coma is formed; nnd the 
ea% becomes one of the utmost dauger. There is now no tolerance 
of active an tiph logistics. The lancet is laid aside. Purging ia 
cantionaly continued. And the main rtliance is placed on i^werfiJ 
CO u u tcr- irr i ta lion. 

Kven with<iTit effiivion, recovery from coTicussion ia often tediona, 
and hnperfect. The eye renndns wild and variant in expression; 
memory is impaired; conversation la childish, and often incoherent; 
sotnetimea tbe deaicanonr is timU aod gentle ; sometimes the patient 
is very irascible, and apt to be moved to much violence. In short, 





20 



TREATMKKT OF CONCU8310W. 



there remainM an imbecUity of Ihe wliole menUl powers* In otlier 
Oiaoc, certain only of ibe menial fiicnllieg tLiis suffer; aiid of those, 
momory is the otie moFt frequently uffected- Somclimes ihe recollec- 
tion of all [fast evetils \s cillier loal or obscured ; sometimes a portion 
of these rt'iDhin tolerably viviil and diftliuct. Sometimea Ihe past ia 
untouched, and tiie present only nfFi-oled. Extrflonlinnry n^Finlts have 
occurred, in rt'^urd to languages; when tlie kuuwltfd^^G of a plurahty 
of tliCBo liaa injen prcvhiusly possepsed hy ihe pKlient. Cerluin of 
thera have gone qnite from him ; and on recovery frum the first effects 
cf ooneuhwon ho hiia pfxtken with fluency, and continued to do bo, in 
■ tongiio to wiiidi hu had be fU lu";!^ « fctranger." 

Again, inlollticl mny remain clear and entire, while special aetifie 
euMainn an injury. Heannfj and smell may lie lost, impaired, or 
IHirverU'd. WrakneBH of si^'hL, with or without BquinLing, is no rn- 
conunna result. 

Kuril rcNiutc and chronic connequencea of cnncuBrion may prove 
but lj^Tij|horary^ ; or Ihuy may remain for life. The alTcclioiiH of the 
inlhd Ar** oK[ii"r'ijdly liable to prove oballnnle ; nEid onglil always to 

rt^(!i?ivo a very ^rnarded pnignufiiB. The treataieut fnuud most euitable 
conitiwlD in a mild allerutivp mercnrial course, wilh moderate and long- 
e<nilimn'-i rnunU'r-irii til lion ; an uiilfumdy lax stale of the bowels^ 
■nrl ocTunlunal purging ; n mast c'arefully rt^^dated diet ; reetrictiou to 
m-rtliTjili^ *^M'iriw« »f botli hi>dy and mind, hot mote especially <if the 
hillnr : uviiidmini *if all Mioivf^s nf inenlnl tscitement, especially of puch 
an ivf'* known Ui 1hi hi'Pcilinir lo llie patient ; ihe n&i of the cold siiower- 
Imlli i ami rmidi-ncc^ in ^joniid L'\i»oHure sind elimate. 

M/Luy paiiruiH ri-ffiver, li; all flppoannice, nerfectly from concus- 
■fun J nud yea nn* HulijurL lir fri'ipuMil a^ui uiipleflsaui remembrances 
(tT l]*c* iiijary. On atk*ni]iti!ij^ miv umiwiid cSL-rlion, either uf mind 
or fwidy, iir oa lln* c^rmrirnpe nf auv (ith^^ruiJio iriflini^ elomjichic or 
hjIfHliiial (1in>idi>r, iolMiHii hnulmdi i<!i|a'rvcni'P» uilh some fever, and 
lH'r\ui[m altiiiiih^d with diKurdur of si^jhl or other special sense. Or, by 
•vwi kliKlil liidnlHeni'o in miu\ Ihey are liable to under^ great 
fimitftl rurlLtiiiMhl, liiiln wliort i)f lempiirary dehrium or insanity- 
Hnrdi |j»riiiinN^ it U rbvi-»ij*, mii^'ht lo \my pruia altention lo regimen, to 
\Ut' Alrtin nf tiu' hi>w.i|«, und lo IIh* avrMuiuv of all circa niKUncpa 
\\kii\y ln*.Ki-)lrs itr (^aUKii dHrrailiMsH.^n lo tl»- rrauialconleids. hide^l. 
It ina) iih \M d.ivn mi u huU^ ^<-uvrii\ nde, Hint all who have once 
<in«lHhi'") any inn^liliM'ablii luuicnt-sion of the brain must ever after 
fi'«iihi \My U.i.\ a-.aw.*ah ihdnl. nvhklj n-quiri'S cousiant propliy- 
la*<fJo ram. And, fnr h-.io- liim^ inoaediab'lv trtiee^cdii.g ihe inflic- 
i\m «r Om Injnryjhl- Imlli nhouhl Im nun-u .'si^^^cinllv forL-^d x^>on 

Uwirr- ri.r, *mMy ^rvioiip <^whn] dibor^hrs have UetL the 

'"""'' "' !"■' ''""^ ^''I'Mn (o bndily »*x.'^ei^(^ niealal occutuni™ 



• hir Ah I'liiiVUH'ii li.irniT^*, (1 113, 




COWaEQDBKCEa OF C<tNCU9SlON, 



21 



p 



pleasures of Iha table, after a oonciission Uiought nt the time to be but 
trivial. 

A verj inaidioua, and consequently dau^rouB, affectioii of Ihe 
brain is ftpt In ensiw m a remote coiisri[i;eiice of ooncmsion, more 
esjM-dally in young i-eoiilen A Bli<^lit ii^jury of the lead lias been 
rec*-'iveU, by a b!i>w or fall ; and its iminodicite effect* eeem to be salLs- 
factorily recovorod fvnn, WtrnkH—or, it may bo, months — aftcnvurdB, 
tbe imtieni h out of health : he losea colour, appelitt^, flej^h, and cjio-rgy 
both ut' body au<l niiiitl ; ho is eubject to hcafiach, and occasionally 
Ci>mplaiuB of giddiness; the hkin is dry and feverish; the B^'cretioiis 
are altered ; Ihe eye has an unwonted expreasionj rather of languor 
thaD of yxciteuieiit ; thf Hloniai'li is irritable, and ot:cii« ion ally rpjiieLs 
foud } flWp is diatiirboci n^nd unrcfreehiDfj. The ordiuaiy remedifp, 
direiTied to elomach, skin, and bowels, fiiil to relieve. The geneml 
ailment continues slo^vly lo advance. By and by, tl'e ^^^ symptoms 
afttniQo a pre^cminenee ; and at no diBtaut period IVooi that event, 
symptoms of pressure on the brain becotne plainly manifest. Moat 
prohiihiy ihe i^sue is fahd. An ififlaiuuiatory pioeeta has heea tilowly 
(wlviiiichig i(k thfl cerebral eubfitiincc; pupj^nrntiim bna at IcngLh 
un^iiired; And, in Ci"iseqnence» it in not nnlikcly that an acnte acces- 
sion has sujiGrTcucd nn the previons chronic change of structure. 

It is very obviouji how the inubservaMt practitioner ranst lo apt to 
iDifttake the true naturo of such casen. The head is not euspecled of 
originating the evil, until towards ths close; when treatment, however 
flmtftblc, OlIii prove of hat little avoil. Diet ia attended to, laxntivon 
are given^ t''^" alterativi-'i ; and then, prrihalily, lonies; all wilhont 
relief: tile last chias i>f remedies inevitably inducing- marked jijrfjrava- 
rioFL of tile disorder. It may be that the Irealmeui is fn)m the fii'st of 
a tonic nature, and blindly persevered in, notwjihslandinjjr its mani- 
feat failure; the n^bult ia eonst<pient1y t^lill more untuw aid ; uud coma 
io rendered more tarly, more urgent, und more htipeless, than it olhcr- 
wiso mi^bt have been. The treatment, on the contrarVj shonld be 
such as to counteriict a chronic infiamniatory proccsa; conducted wiib 
such care .ind skill as the iuiportanee of the texti^re implimted ao 
imperatively demands. Leeches are applied to the temples or tsrciput ; 
and are repeati'd, perhaps, once and again. The head is shaved, aud 
miMleralfi countor-iri'itatiini ia patiently iiiaintmnod. A mild tour&c of 
meroary is given. The intuslinal an<l other excreifons are Attended to. 
Diet is sparing, and most carefully re^dated. All escilenenl of both 
body and muid is avoidc*!. And sncb Ireainient must be duly main- 
tained, notwithstanding the patient, or other ineiperienced observers, 
may not scmide to say that its rigotir is quite ditprojHHtioaatc to the 
importanec af the cilto. The BiU'gcon kaowj* the inmdiuua and covert 
nalnre nf the evil u-ith whieb he is callpd iqKin to cope; and is not 
'"^ived by appearances. Hib main difficulty may lie iu enforcing the 
Msores which he knows to be essential. It were well that patients 




22 



COlifPBESfiTON OF THE BRAIN, 



wen; in general as fully convinced^ as are the members nf ihe medkHl 
profession, of the trutlifulntss uf the nxiom, lliut " no injury of ihe liead 
[B too Blight to be Respited ;"' and that whenever nny woriouB poncUBBion 
hiLB been t^nslidned, ihe grtatenl prophylactic caution \& expedient, long 
afler the itifliction of the injur}'.* 

[t 13 neerlleaa to expose tlie nnsnitablenesB of the oiwraliou <if tre- 
j>hitiing, in all cases of simple coacussicn. 

Cojnpr&sion of the Brain, 

It is nntiecossary here tn consider the fineation. Whether the 
Biibstance of ihe brain is capable of coridensflljon by pressure or nnt. 
We know thai pressure applied to it, according to its sudJennees and 
intensity of application, prodnccH Jerangenient of the funclious of tlial 
iinportflut texture \ awl tbe coiistqueiit ixeXn i»f symplonia, varying in 
dGgtt?G, flro usuftlly lermed thoa© of ^'cnm[ires*jetl bmin/' or of " com- 
pression." 

In concussion, the whole brain ie affected ; in iximpreasion, a portion 
only may be acted on. In tl^e one case^ the cause of disorder in of 
temporary application ; in the other, it is of some dutaiion. The 
ftymptomtt, therefore, may nAtnnilly be expected to differ. In concoa- 
sion, tlie dopressing t^K&ci on the heart atid general cir^'iilntion is 
immediate and piriniincril ; and the patient lies pale, cold, and pulseless. 
In compression — tlip injury l)einj* itJ^nally limitcil lo bfit a part of the 
brain — the bcart's notion may, at first, be little if nt all affected; the 
akin, conseiucnlly, may mtain its natural warmth and hue, and the 
pidse IIh fiducBs. Tn conuu?<wun luimedjaiijly fatal, dtiLth takes plfice 
by Byneoi>o^ In onrnpreHnion, llio fatal rn'Bull ie due to coiaa> The 
essential pecnliarit)- of tlje latter i^ 'Mhat respiration takes place 
imperfeotl)-, aitd nllinialcty in Mispcnded, probably by rcixson of the 
defect of wnRation. The* circulation, and Komecimes the animal heat, 
not only continue entire np to tho moment when tlie last breaih is 
drawn, biit ev<!n Kiirvivo tliM ri'Hjnraiion for a short lime ; iluHnj^ which 
time, of etiiirso, vooouh blmul mi>\'es along the nrtorit'S ; but ihe vtnouB 
blood, according tn the k*'1"'''"I biw fHtjildinlu'd in tlie physiology of 
reBpiraliou, soon censew tii make il« way throut:li tho capillaries of the 

lung;s, and the circidulicui in llicrrforr noi-n biMn;;hl to a stand 

We know from physioli»iry, (hat the part of the ucrvcuis system which 
mnet lio s[>ecially uflWtcil in theKi^ riii^iiH, \/\\\sn Ihe failure of respiration 
IB the immcdiiile caiiho of dciitli^ mitsl bij at ihi* sides i>f tbo mei^ulln 



I 



•"Tl will En c^nernl IwfiniTut viry illniihll Cn iidr-UK^trtu (wrpon whn Im* tifl'l wbat 
mof l» nillftl only d ktKK'k on Mu- |).ilr, To »ijlpinll (m iHmliptlnn.fhi^i'inlly i\ U^ Iiml tiini' 
»lf "..li-mlilj y*^\- lit win Iw IniltriiMLlollilikk tJmL \t^v' -iirui'^in !■ cUhemnnowssjirilj 
ipprcLcnAlv?, irr trniUy of n inui:h worn" Imilt ; uikI yo\, \t\ mnny tnitniiiv, ttiv llnuly 
»u 'ij UiF np^lofl »i till* r<tiiglD ruauHJy (libuHL-tiittltiK) uliIih fell \\\ts lUlfetvia^ brtTeec 
l»fp|y ana fulfllitj'."— Pott, \. 47- 



COMPBESSIOS OF THE RHAIN, 



23 



I 



obloQ^U; bu( tbe part visibly injured i» oflea conraderabi; dislanl 
fivm lliifl.'*' 

FrtrfiAiirc may be iuacIo on the brain in varioiiB ways. By extn- 

vikMLtion of blond ; irk ilB siibstaiLOe, on it8 ?iirfn<!(?, or b«tw^*«n tho 
raeinbranes. l!y formation and accamulation of pna, or other prodncta 
of tbe LQflimraatoFy process; also, either cerebral cr intra-mem- 
brttnous. By frncture of the craaiuoi, witb depreasion of the broken 
part ur parts. Dy lodgment of foreign bodies in the brain, or on iia 
anrfiife. By the formation of Aflrontilious growth, in cunntxion with 
either tho crariium or its conlentB : exostosis, osteosarcoma, or osleo* 
cepliiJoTna of the oraniiim; tubercular, or other tumour of the brain 
or its membraties. It is probable that contpresHion is also occasioned 
by mere congestion ; a itate of over-rtislensinn of the blood-vessel*, 
with arlvancing serona effusion. 

ll is highly iruportjidt to benr in re men jb ranee, that eymptoms 
precisely similBr lo thosfi ^^wiinarJly protbicetl by pompreftfroa of the 
bniin may be, and frequently are, induced by other circumstance*, 
wlien no apparent pressurf ia in operation, t^ertain poiaons, for ex- 
ample, have rliis eETcct. Bat what is of more consequence in a snrgi- 
cal point of view, such a train of symptoms almoBl invariably attejids 
on disorganization of the cerebrnl tiasue by iiiflatumation j and that, 
loo, when the inflammatory prrMliicts seem U' hp of mirh a nature ab 
not lo occasion pressure in any great degree. 

la surgery, we have chiefly to do with ihoflc examples which are 
induced by depressed fracture, extrftvasalion of blood, inflammalnry 
exitdalion, and suppuration. 

The most Gha^act(*^^lic symptoma are found affecting the respira- 
tion und the pulse. Breathing is slow, labouring, and loudlj slerlo- 
rons; in eono\i?sion it was gentle and aig-hing, A peculiar wbiiSng, 
hy the moDlb, is not iinfrerjuent during expiration — as is observed in 
smoking, or in the or-linary repose of heavy sleepers ; it is a symptom 
of untoward portent, Tbe pulse is distinct and full, usnally slow, but 
often at first notnjuch altered as to frequency — not imfrequcntly inter- 
mittent; in conensBion it was frr>m tbe firbt rapid, low, and feeble, 
perhaps wiiolly imperceptible. Lobb of consciousness is more com- 
plete than in concussion; the patient cannot bo roused by any move- 
ment or noise. Loss of Bensation is more complete; he may be 
pinched, or bumti without in any way evincing jierception of pain. 
Special aense it wbolly dormant ; Lt.- neither sees, nor bears, nor snielJa ; 
at least no rcmilt follows the appUcaiion of etimuli to tbe eye, ear, or 
nose. Power of motion is wholly gone; the volanlary musoleG are 
relaxed, flabby, aod powerless; the limbs lie loose and incapable of 
motion. The eye is fi^ed; its pupils are dilated and insenKible lo 
light. Tbe skin is of a normal temperalure, or perhaps even warmer; 
not unfi^ucntly wet with [Kispirafiou ; in couciis^iou it waa cold, 
* A-tdUOif , OutliHS of Fubolaig7t p. 0. 



1 





24 



COMPHESSION OF THE BRAIN. 



pnle, anil nlirunkeii. Tlib spliiucters are reluxed; f^cea pufis inTolun- 
taril^, Expiil&ivc miiHi^lcs are BUitilarJv- afftctcJ ; Uie nrint; is, in con- 
seqTioiice, retn-inKl ; or, fri^iii [larnlysis of iho spliincter us wpH, iJie 
urine may pa.«a off involiiEjiarily, unt !n u strejim, liiil Ly dr<i|)a. 

Such is liiu gerienvl cliaructer of llie symptoniK petuliMt to com- 
presaion; varying, of cuui^se, in cic^ee, accordiiig lo the amount or 
nature of llie injury sustained. Tbey are of immediate or eeconiary 
ncceaHion, according to tho causp ; ini mediate, wLon tiic cooatquence 
of andden LemorrliH^, d^presst^l bono, or iinpactod foreign boily; 
HGCondaryT wlieii tlie result of tarriy extravasation, snppuratii^n, or 
inflammatory exudaiion, Howevi?r origin aling'» lliey arc, after a time, 
masked and modifieii by tlic resultfi of the inflammatory proceBU which 
seldom fails to become establialied 'm tho lujurL^d pivri. 

But the brain has thu power of recovering from tlio effects of 
presanre to a certain extent, even althongli the agent of conipreseion 
undtTg-o no alteration; the org:an seeming: to accommodate itself 
gradually 1o its cbangu' of circuintilancesH ThiiST in depreBsed frac- 
ture, symptoms of comprcssJoii may be at first marlted and even 
lurgtnl ; and yet may pass oft' io a day or two, iviihont any elevation 
of the depressed portion of bi»rie. TLia Ifclng home ili miuJ, we can 
readily iindci'stanil liow^ Lv (bt- time llinl the biflatnmalory proeese h&s 
begun, the symptoms of conapressioii, nt first considerable, may have 
in A great ineawnre [lati^cd away ; and how thi^ cjse, consequently, may 
for a tjjoe prc&etit oidy the orrlinary symptoms of ur^'eiit in flam ma I ion 
in the brain and its mtmbraiifs. Tbia la suiueiliinj: more than mere 
uiabking uf comp^u^ail »ij by the infianiniaiorj pruei-as ; it in Mipi^nwd- 
cnco. Certain fnnciionfl of the brain aiy plidaly re-establithu'l, though 
perverted ; coiivnUivo movements of die limbs occur, and delirium 
may su|M?rveno. 

Compression may, like concussion, prove directly fatal ; the jmtient 
perishing by eoraa< Or — when the canse of pressure is removed, or 
eveEi, as already staled, indejiendfiilly of this — the M'mploins grmhudly 
abate, and tho patieiil blowly ret!ov<?rB, Or, ere yot any groat Uiiti- 
galion in the syrnptnma of eomprehsion have occiirretl, those of an 
urgent inflammat-jry yrnvu'^H kintlled in Die injured part become estab- 
lished ; aud Ihe^e jnovo fatal Or, a sijuibirly fatal issue may lake 
place, thron^'K iidhimmaii^ui, ev<!ii idllnmi^di Iho immediate eftects of 
ccimj)reHJ<ioii ha<l Heenj''d lu have U'lm n-ruvirod fioai. 

Tho indi(?ations of In'iUiti'rit iulupk»d Uy r-(ini[>rehtji^'n arc Befficitutly 
ample. To rcmovi), if jioBhjblr, the euinpninsiii^' cau«e. To walcb 
the subsequont fivmirable pri»j^'ri"M of the ortjan to resumption of its 
normal slate andtuiiclii*!!. Tu intdrf'ire, if iieeit l»i, tu avert inflam- 
mation, And to onjiohu the ((nlowurd (L'lvnhre nl' IhJH, uhen unfortu- 
nately it hiu* Unuin-' fslkbliNlindh Wlu-ii * . iMprnriiH orKiin|(le euinpresslon 
permit, without uny op|Hir1iniily Udn;/ I'tV^fU-tl c-f tvaitjviiig (bo eaiise 
of preunre, t'l miunUiiii by Nullnhl* iitfnuit iU" mWou of ihe heart and 



i 



COKUtlSSIOW AND COMPRESSION. 



25 



hinga ; SQ ftB, if ^MiBsiblt, to affbi'U time for the bmin, by acoommudiiling 
lUolf to its ftltereJ I'lrcumBtancofl, slowly aiiJ imperfccUj to refiume 
lis fonctiuns. 



Bt^lweeii puru PX/imp)eB of CoticiiesioD utiiJ Cotuprfssion of IIjg 
brain there i-s iiu 'liflioiilty in drawing a BnfficiL'nlly brtwid dfaiiiitlum ; 
in practico, as well ne in theory. Tlie ono, a wise of avncope; the 
otiior, of cnma^ Tn ciiTiuUdsioii' — Ilie B^raptiiiiift iramedi/ile; iimensi- 
bilily iiBiially Jncomiiletc ; the organs of Kjtcial sense capable of Iwing 
rtiiist'l; the lEustles cu»li-ftclile» uml the limbs, under slronj;^ fitimnliis, 
nader^oing miivtment ; the brealhing yoft and ^pnlle ; the (mpils not 
unifonnly dilnltd, thuu^h insenfiiblti to li^^ht; the pulse rapid, unuWy 
imlitiliuct, porliupe for ft lime imperceptible; vomiling ; no iuvohmtory 
ev'.iou&lioTiH ; the skin ooM, \^\fy and shrunk. In compression- — 1h<} 
syuiploms not Dccesaarily iiameilinte ; insensilility cL>iiiplele ; the 
orgaurj *if ^pmal henso incuimhle of being roused ; tbu mtibclts relaxed, 
purnlyzed J the limlhs inutiuiileSB, until rece^iwon of llic slate of com- 
prefision, aud advance of the iiiflammatnry procewt; brt-nlhing laboiirtd, 
ebiw, and ^nonng; iht* piij>ilc» diluted and iuaunable ; the pnlsc gIow, 
difilincl, perliHj« iiill, soineiimes inlerniillent ; no (or seldom) vonnt- 
ing; fteccB pn^sed JTivolimtarily ; relenlion or dribbling of urine t the 
etin warmT and often bedewed by pprspi ration. 

Got it is vtTy plain tbut conipai-Litivuly seldom will pure esamplee 
of either ^tale be presented lo the surgeon. The blow or fall which 
prodinjL-n severe eoncu*-*aion, i» very likely to cause also bicer^ition of 
the Bubshuice of the bruin, or rupture of a vesBel in the memhrauea, 
whence blood will escape, a^ioncr or luler, inducing a certain amount 
of coinpretwioa. And, ou the other band, the injury whith eaiises com- 
preaaioii, wliether by frflnture or ext ravasuiion, luiist, at the h^uic lime, 
and primarily, bale cmiBed more or lets concms^ion. lu conaenuence, 
the two etatea, and tljclr corrcsiionding syaiptoms, are often — nay, 
usually — more or ler^s fomniingleil. Ac^e^irdiii^ lo the preponderance 
of either class of symptoms, tlie case receives its title ; and, BometinieB, 
it is not ca*iy to s^iy lo whal Eide tho preponderance is inclined. 

There ia one class of cJisee^ however, tmfficiently distiiict. The 
ordiaary eympioms of coueusfiion follow an injury of the heafl^ and the 
patient rallies fvtjm ihcm, Consciou^nefls sa completely itfitjred, and 
ift retained for some tiiOf. lint witboul ite operation of any new 
external cftUBe, inseOKibiiily reiUTtiH; uncousciouEne^s in more complete 
than before ; and the symj^tonis now will lie found presenting (he cba- 
ractei'j^ of coma. Here Ih a combirtatirin of concub&ion with compres- 
flion; yet there is no difficulty in scjiaraling the case into ila two 
i^HjDetit parts. The first iasenmbility was lliitt uf eonen^Mon i the 
oud in undonlitedly due to eompresEiim. If lbs interval of con- 
eciousnesB have been brief — of hours — the compressing agent is, 





26 C0«PHE9ai0y BY EXTRAVASATION. 

iloubilesH, eslrjivaHal<?d Mooil ; if It have been of oonsuiBmble duntiirtii 
— ^la^s — the cimiproEBin^ agent is piia, or otlitr inflflmnialory ^)roducl. 
It is riglit also to n?menil>er tliat, nnt iinfri^qiTt'iilly, pnH of the 
iiueDEibilttj atLenil^iiit on iDJnriLM of (Le lu'^d uiay be atlnlxitaLle lo 
intoiicalion ; and that although this influt^nce is of a Iraneirnt itatnro, 
and [n that extent favourable, yet that it prediKposes to iiitlamuiatory 
ncccssion. 

Cotnpreaaion hi/ Extrat^asation ftf Blortd. 

Escape of blond may take place, immediately on itiflicliou of the 
injury; or not until renctioti bus Followed Ibe direet effects of concus- 
sion. During llie deprtSBcd state of circulation which oblaiiis during 
the firel effect of tho injury, no UooJ may ostrtpo fmni tveu cstenaivo 
cerebnd laronitioii j hut if reaction he both s[iee<ly and iutense, even 
the slightest leidon will be <^erlaiu lo fdTerd a dangerous amount of that 
flnid. 

The extravasation may be variously simaT^'d : between the fiknll 
and dura mater; between llie memhranea; on thtr snrfacu of the brain 
— on its hcmiepheres, ot al its b-"wc ; within tiic venlriclcB j or Jnfil-^ 
tritptl into broken-up cerybrai flubstanep. For praehcftl pnrjxKes, it \n 
ftuffieieut to divide compressing extreViiaations into iwo great classes; 
ihrtse which are exterior lo the dara mater, and tliose which are within 
that membmne. 

1, — Extravasation bftieeen th^ Bone nn/I Dura Mater. 

One of the efft-ets of a fall or blow on the heml is, by disruption of 
the soft parts constitnting the acalp, to prwluce mure or less ewdlir^ 
by Bangnineoits infiltration of that texture. Occasionally, a similar 
result ia produced on tlic iiilfrnal H^pet-t of the part, of the cranium 
Btrucli, in tlio aronlftr and \fts<^nlar c:^nticxions of the dura mater with 
the bone. Tlieso lieino- torn* pscjipy of hl<HjJ follows; dlher at ibe 
time, or subfiequcntly on reaction; or at both periods; spftringly at 
liret, more profnaely afterwards. If any cunsiilcrablo vesst^l have been 
torn, the exlravasalion may be especled to l>o both instant and great. 
By ench abnormal nocnmnlatiiHi of NoimI, lhn dnra mater is propor- 
tionally bulged inwards ; anU compropsion of the hn.in ncce&sarily 
results. The Uood, as in other examples of ex Ira vasal ion, is nt Sr*t 
fluid, but sooner or hiter assumes the solid form j or, rather, by coa^- 
latiou it [wparatcB into clot and scrum, 

Eslremo cases of this nature, it is plain, are moat likely to occur 
when thfl injury hua been inflicted in the oonrao of iho ndildlo nn^uiti- 
geal artery. Ami, lo oceaKJon niptnr^ of Hint venmd, it \h mH. nRFwntiid 
that fraclnri.' f'f ihe mjj)erimpofle<l hone ,shonld Inki* [ijnee, MtTe mn. 
ousden may MnfTice. If compound fractura oxisl, tlio blood k moru 



POMPRESSTON BY EXTERNAL EXTHAVASATTON. 



27 




likely to escape pxtcrnfllly, Iban to accunmlHte, to itny inconvenient 
atnodiil, between llie bone hml uiftnbrajiL'H 

An i nil i till ir>tia of tlic ovcut : — In tuli^litiun to iho oTdlnary syrnptoraEi 
of coiujirejisIiinT ne havn tlip ]H'l"U- 
Har Bite and nature of tbe ininry, 
A smart blow bns been receiveH 
in the conrRe of the meBin^al 
artery: and U speedily followed 
by ui^nt ^ymptomB of compres- 

SikIl ciim^iresHioTiB mBV lie so 
grave aa to cause death, by its 
direct e9ecl. Or, farlher ebcaf>e 
of blood ceftfii[% the bnin begins 
to accommodQle ilself to tbo 
amount of prpSBure already a|i- 
pKeil ; at tbo Eame time, (be 
couipreBaing a^nt is bein^ gra- 
dually diminished in bnik by 
absorption of the extravaEated ^*"*" 

blood ; and the paticul elovly recovera. Or the iuBiimmalory proceei* 
\b WindlM aft^r n lime ; nnd unhealthy Rnppiiriklion \s npl. to ^iiKne; 
reindiicing symptoms of compresfiion, more urgent than before, aflor 
perbap** a considerable interval of conBcion^nops. 

Treatmtnt. — When the circumstanceH of ibe ca^e aro Biich as lo 
leave little clonbt as to the otxurrcnce of this form of ostrava^ati(m, at 
an atcefiHiblo find defined p<jrtion of the flknllT we can havo no besila- 
tion — if ibe ByniptoroB of pnmpreefiiun uro nrgent — in ijging the tre- 
phine ; for tliG pnrfwse of exposing thf* eite of extravjinalion, and 
effet^ling relief by evacuation. If tbe bloiMl be Mili fluid, it escapes a.t 
once^ if cougulated, tbe solid poriioTiR may, if need be, Im? detached 
by a pnfbe — dolicalely iBed. 

Unfortunately, wo farnot be certain, in almoBt any case, of tbe 
eiftct sile of the eTtravapalKin ; and, ecinRefpienHy^ both txir operation 
and pmoTiofiis rerjiiire to be extretnely gimrded. A concusbiog' blow 
operates chiefly on two parts of the cranium ; the pait elnii.'k, and the 
part immediately opposite ; tijc rino cfieet often lenned the vi'up, the 
other the t-^ntrvcbup. It not unlrequoDily happens tbat esiravasallrfn 
takes pUcc in the Inlter sitiiatinn j not at the part stmekp But fail- 
ing in our seapch at ono pointy we are srnroely warranted in making a 
similar attempt at the other ; for the extravasation may be yet elee- 
where, in a Bile not aacertained, and perhaps inaccesdbJe, 

If the symptoms of compreseion be not urgent, i^-e do not interfere 
by operation. The brain gradually recovers. The extravasation 16 

Fie- ^- lilitrjiTflMtion uf hloo.1, m^pantinir ibo dnm matfr frcm tlie craniumr at tb« 
DfiUjian' tl\i:\ by rupiiirt: uf Uie uiJitUlv iDcnlngeal nriery, ". 




28 C0MPBE6SION BY INTERNAL 15XTBAyAS\TI0N. 

Blowly abftirlwd- Otir duty is to avert iEiflnrumatiuu, if pofisible, by 
the ordiaaij means ; to modernt« it, ahoiild it occur. 

It. — Ej:trava3atii'n tjf Bt^md o/i^ or in the Brain. 

As ftln^ady staled, ihe blond may bo variously atualyd; inlru.* 
menibranniis ; dilTiiBed im tlic siiifico of the heminiflKirPs, i>r at Ihe bjise 
of Llio brain; wilUiii I'le voiiti'iL-left; or iufiUiAtod inio the cerebral 
tissue. Aiml, niifortunalely, llie must paruful examinudon of Uio liis- 
tory» symiiloms, imd pro^'ress of tlie ciise, will often not eiiablt? us to 
ftscerlaiii, with iLuylhing like certJiinty^ tbe exact site of tlie evil, 

Tlie sjmptoma aro those of compression ; more or less i;rgent in 
their cbantcter, ond more or leas K;>eedy in tbeir acceBsioa, according 
to ibe ait^f mcouiit, mjiklityf xluA tiujc of (be exirn vocation. Usually, 
tbe oKcflpe of bluod i^ not immediate — jit least tci eiicb an oxlent as to 
caiiSH Ryraiilfims of (leciJed coinprcsHJon — -but se(^n'iftry, ori the occur* 
r*?n<u' of reaction, Tbo pitlient may havo been from Ihe first inseu- 
Bible, by c^mcnsdoti ; And ibis minor inscnailility nmv l>e tdmply 
merged in tho major insenBiljiJty of compression ; or lictween tbe two 
Ihei'e may be a greater ur less interval of conBcioHsnesa. Tbe cerebral 
or TTieDibpunoiis le^irm, U'hicli pertnitR tbe sQng^iinooufi escfipe, may 
fidkm- Oh a couciiasire injury i)f tbe cranium ; on estfiisive fracture of 
the cranium^ with or without depreBsion : nn mere fitrfiure of tbe hhull — 
more especially when (his is situate at Ibe base ; or on a penetraling 
woniid, of any kinil. 

There is tlie same proguosia as ia tbe case of extravasation exterior 
to the dura mater. Tbo brain may recover, and the eKtravanalion be 
absorbed ; or the brain, reoovfinng parHally fruni compression, Buffers, 
perhaps fatally, by inflammatory scceSBion — immediate or remote ; or 
the compression is most urgent, and dlrei'lly terminates existence by 
comn. Kiipidily of extravasation iti more imi>oiUnt Iban tbe amount ; 
and tbe sile of ibe escape ia of more consequence than either. A 
comparftlively small qnonlily of blood rapidly^ or at once, eslravasated, 
will induce, more nrgput Kymptomn of cnmiiresHion than twice the 
amount which has slowly oozed from the torn vessela^ and while a 
krgc flat coa^^ndum may press wilh comparative impunily on tbe 
upper and anl?ri*jr part of tbe bemisphcres, a slight amount of blood 
acting on the base or tbe brain — more especially at its po3ti*rior pait — 
never fiiils to IndticG tha most Eciioua and T;rgent conBequcticea. 

TrFalmeiit. — Preveulion may bp in ouppower. Concussion may 
occur, along with slight lesion of the cerebral substance; and from 
this lesion litlle or no blood miiy esciipe during the period of depression. 
Tbe injury having been s^icb as to engender a stispiciou of these cir- 
ciimatances, it i^ plainly ciur duty to protract and repress renclioa ; 
when it does occur, to endeavour that it proceed elawly and calmly ; 
or, if need be, by bleeding frum tbe syBtem, to reinduce the state of 




COMPRESSION BY INTEBNAL EXTHAVASATION. 29 

depreBBion, aiii mftintain it during a second perial. The object Wing, 
to n-ffurl limo ami opirtirliitiiiy tiir efficient iwchiainn <^f the iitjiired 
vessels by naiiinil ht-moslJitics, If too liile, or otherwise unuhle^ to 
prevent; wp may jet hope lo modoratu and liniil the estrnvasation. 
And this is lo ho (^fTL't'ted by opposing reaftion - keeping 1 lifl patient 
quief, with the head elcvHte*! ; applying cold to the head, fAce^ aiid 
neck; iotertlioting all nutrili\-e irigesla; taking; blood from ihu sjstoui, 
aa circitrastances may require ; and acUn;,' freely on the buwels by 
piir^alivcft. Our object slill \& lu Lavw not only llje general circula- 
liou quiet and genlk» but to linvc bljod circnWing within the cruniiTOi 
as fpuringly and as calmly as le conipatible wiib s«ch mainti'miace of 
the cerebral funclions as is esst'niial \o life. 

Exlriivaaiilioii having ceased, ue btipe that in due tinie the sytcp- 
toma of crinpression will begin to abiilt; the brain necomTnixl^ting 
itself to the ciMji pressing agem, and tliia latter be-anmng to diniinisb 
by (ibsorptitui, Wu waxd vtT hillammatory nvrnpicm^, should they 
threaten; anrl maintain airict rust, qiiTclude, ?ind regimen; tha last 
being very rigidly limited in regard to hoih fluids mid solids in order 
Uiat there umy K- a Htnte (jf aj'sttm aot only iinfavonrable to inflauima- 
tory accessioii, but als(> favourable U> absorplioii of the fxtravasated 
blood, Uufortuuately, wo liave no direct means of asaiaiing in the 
laUcr indication. 

A paramomit intlieation andonbtedly ih, remoral of the compreBsing 
canw*, the e\tr;iviifyLtion. ThiR oau be arlifieially effeclijd only by 
operaliim ; by renionng a pi>rlion of the craifiuni ; pnnctiirin^' the 
mtmbraneti, if net-d be; eitpo^in^ tho siti? of extravasation, and pef' 
milting— if not eflecting — eiTemid discharge. Were the operation of 
trephining callable, always, or e\(rn often, of achi^^ving this rei^ilt, il 
would bo hold as gtnorfllly ndvisabU' ia,Bnoh cast's. As it is, bowovur, 
the professltin is much divided upon the question ; i^nne in favour of, 
othera o[i|HiPed to thu proctredlng. Among the latter \\g wonid Inig to 
be enrolled ; and for the following reasons : — I. It i« difiicuU, if not 
impoBsible, lo delermjna at what part of the p^iphertf of the cranial 
cnvily (he extravasation buA occurred; whelljcr aX the point sErnek, 
or al (ho eito c>f tho contr-pcttvp^ or at eomo t>rher j^rt — etiperiody, or 
laterally, or at the ha^ie. 2. It i^^ eqiiilly fliffienll, if not imiMiSfiible, 
to determine previous to the uijeraliiin, at what part the extravasfttion 
has eecuiTorl ns rt'garda the dkii^iitttr of the cranial eavity ; whether 
between the mcmbranea, on the surface of the hraiu, williin its ven- 
tricles, or in LtH broken \\\\ tiEsne. 3. Supposiug chaL the ex triL vacation 
baa been reached and exposed, it may be found either vliBicnU or 
ittiposfiible to efff»?( its renioval. Coagulation has taken ]ilace. The 
fiiiid portion trtekles aMay at onee; but the clot \% expanded in Ihe 
fonn of a tiat and broatl cake, wbicli cannot be dislodged and extruded 
withoiil the iuflicfion of such further mechanical injury as shall render 
the oceiirrencti of difliuiruua inflammaiarj aeiiun inevitably certain. 





m 



C0MPIiES8I0N BY EXTRA VA8ATI0N- 



4, Sii|>p<iHiDg tlint tike cofk^ltiiu bft^liecn exposed uid nol r^moveil, 
the [atii^nL L8 obviotiely much mure unliLvourably situated nfier iLuii 
lioloro the o[»^iution, Ndw tlicre iti a t-erlaintv of ioHnmmatory accea- 
Giuij — Jri miUiiion to tlii^ Qiirtlicved evil uf coin|irvsnio)i j auU^ miiJer 
tljo comLhiatioiij it is but too Uki^ly tlint life uay pve wAf, Bofore, 
there v^'os but the eoiupre.ssion ; inSrhmuiHtLon might have lieen riverted ; 
tha brain, Iiy Acot>mu)i.Hlatio]ii might Imve gradually recovered- 



ThiiB, then, we hnlilj thai in ihe i;aau of comprtKsion ly cxlrnva- 
Biiiod bluod, tiiu operiiliua of trephiLiiiig la to be conbtdered &s generally 
inapplicable. Oj>enkting, we are uncertain wlielber or not the irepbine 
is over the site of extravaantion ; we arii uncerluin wlieLher it mwy be 
TWceHory to jiimclnre the nieuibr!i.iich of the Iraiii — anJ, lliat having 
l>een diHie» we may Kiill fiiil in exposing the blood ; we are mioert^n 
i»r bi'iiig Jible to remove the bliHid, oven after it baa beei] exix>&ed ; ami 
wc are almost corUiii to light up aJi itifliimmutoiy procuea of a. must 
ur^ii^ und jTorhn[>s untnniiageabU character. In cjtJicr words, ua jire 
anre to iiiflit:t injury — by iieribraliou, and expi-siire ; we may sua-ee*! 
in conn torbal arcing this injury by a prepondemtiiig amoimt of benefit 
— by exiruw<ni of the compressing >Lf^enl, the eHL'ai>ed blood ; but ve 
are fully more likfly lo faii in ohlainini; the conleuiplated advania^ ; 
Hnd then Ihi? (iroccciliiig jircivcH to be ullof^tilur iiijurioua. 

liot to flU gonenil rnldw then" nut lyei'iiliiUiB. Ami here tha ex- 
cei>iifin conaiat* in those cnscs of injury applied in the coui-so of the 
middle menin^jeal artery, irumediati.dy fnllewed by urgent symptonia 
of compression, with or \v'ithon[ fnicture of the skull, iti whieh we cun 
huve liule doubt of iho fullinving cirenmulances : — I, Thiit the com- 
preae^in in canned by eNtrava?4Ation of blood; 2. Thiit tlu' bEooi) \iis 
been extraviisak^d at iir mvir Iho puiriL strnet ; 3. Tliat ihc extriLvasa- 
tion LH [fitnate exliiriiirly JiMhi! dur.'i ntati-r ; 4, That the blooil is yet 
mainly flui<h juid IhuiefiMV likely lo e^ciijio readily ootwardn, on an 
ajK'rliire iif eoniiiinrdeatinu Irt'ins i^slnblisheil ; 5» That even if it have 
fOJigulatrd* exirnsion may yet be effecleil, \villionl iieeeesarily exciting 
inKauiiiialiuiif eilhor in thi^ limin I'V m luiy of its meinbrance. Under 
wioh oiri'innsliiurc'fl, wit itooii not hosiliilo to ivpply a tTpphiue to the in- 
jured |iiirt — wln-n th*- nvjiiptoms of couipreftsion are suflieieuily urgent 
to demnnil tliri'el irUoircrem'O — with the full hope of ttflording moat 
iui|>oi'laul iiud h^diUary relinl'. 

We cau nlw^ t*onryivii ii pitwiljlej ibiU an injury may be sustained 
at Ji |mrl of ihn inaniinn nol vnniircied with the coiirw of the menin- 
IfffO aHi^ry; ll^at ihi' h^mploinn of ponipnwiioh by oitnivflaation may 
bn Ihith vi>ry nrj^^nl nnd vory i^hiin ; aiiil ttial tlie sur^'eoii* after can- 
ful enaniiimlioLi nnd roii^iili'ialion of iho rasv^ niay fee) MUisiied thai 
ihi' n\U' ef rxlniVHualion <'iinvw[>(iuiU lo [h(> |iatl slruck. The irepbiuo 
IM applied. If blooil bo found n1 ihul ihuI, oxictior lo the dura mater, 



CUMI'KEBSIOK BV KXTBAVASATICN. 



31 



iLv UstLo b nu«t fortunate, Bui if uc Lliiod 1« fonndr twu qucstkiiisi 
naturally arise : Aro the membranes of iliv brain to be pcrfuraled? ur 
u nnotbar part or the crauiol ci>ut«utH to be expo»«d by reiL{>pHi;ati(rn 
uf llie ln"i>biiiir ? The letter [jue»iitin i» cctlaiiilj lij be inswetv*! m 
tho uogative ; the foniicr, iu the aflmualiTe, only when th« dura mater 
is elevaLeJ through the lrei>birie-}joIe, tense, comparatively nou-pulnat- 
ing-, perhaps fluctHaiin^, or otherwise aOurdiii^^ tolerably distiucl 
evidence ol' the eoiiglit-for blood being lodfc'ed beneath. 



Comprcuion by Ih^ AccurnuUUtQn ofPuthctwcm U{e Cranium and 
Dura. Atattr. 



Such an occurrence may be preceded cr not by Ban^iQeoiia extm- 
voAJitioi]. There lUAy be at £r^t diJ^ni^jtion of the dura mai<:r from the 
internal surTace of ibc cranium, with aeeuniulaliuii of blood between ; 
pcrbapB to eiK'b an extent ue to cuti&o compn-sbion of ll^e brajn. TUjjs 
organ stowEy recovers; and the pnlJont seems convafeficcnL But, 
after some dayts, the iuHauimAtory proccH \s kindled in ihe injured 
part; Kip[)ura1ioD occurs, and the inlemal bnuse degencral^ft into 
an unhealthy absccb!^. 

Or ibere may be no preriune extravaJ^aUon. The Ixine and dura 
mater snatain a shock by Uiq injury, but uiidtrgo uo diAnipli'rn ttther 
of themselves or of their conuexioriK, TUere may l»e at firel Nomr^ 
symptoms of concussion, ami these pass away; but convaleacem-c 
is interrupted by febrile Jitlnrbance t»f ibe system, fol1<iwed by ^^nup- 
tomB of compression. The inflammatory process boa !ven eaublisbad 
in the crafiium, in the dura mater, or in both; aijd abscem fomui 

between. The inttammaliun may bjivc originated in X\iO uiembraiiF, or 
in the conneiiniis of thiH with the lit^ne, or ilk the bone; tit il may 

have be^n in the diplue, can^iing abdceEt^ there, and extending inwards; 
ut the origin may have been exterior to tbe cranium, iu tite soft [farts, 
ftecotnlarily involviiig the corresi)onJing portion of the interior. 

If a jwrtitjn of the cranium have been ruilely stnp[>ed of its j^ri- 
cTauinm, it may di^i ; bnt it dc>ca not necessarily do flu-»a« waa 
formerly slated- Should necrosis take place, arJ involve the whirlc 
thickufiss of the rkull at Lbiit iminr, there h ne*:''^sarlly detachment of 
the dnrA mater, interpcpsitioii vf pus betwi-en it and the bone, con- 
sequent bulging iu^i'ardf of the tfjeiubraiie, and proportionate compres- 
sion of tbe brain. 

But dciacLineut uf the jrvricraiiium, nilh advancing nccroflls of ibe 
extenjal part of thv bone, doee nut iiee4?aHanly imply a corre«pondifig 
?.tate of tnatiers within. The isiiie may be, and often is, merely an 
e^itemal evfoliation, 

Tbe dura maler \b a more im^rUinl and rBicicnl membrane th«n 
tiic pericranium, an regards vascular uutntioo of the bonv-- Detach 





82 AHSCESS OP T»K DUHA UATER. 

the dura mater, and the bone may hardly live ; strip off the pericra- 
nium, ami exfoliation is hy no means inevitable. 

If the injury hiive not only denuded the external lahlo of ifa 
inveJiting membrane;, tut hove also removed, at a correspoDding 
point, the dura inittcr, by disrnj>liijn mid coiiHtqucnt extruvaaalioni 
necrosis of tlio porlinn of li'mo ko circnniRtampil, necessarily involving 
aocumnktion of pus between the dura mater aiid cranium, is inevitable, 
AIro, if the (Inra mater lie alone iletadied, and S[ibHe<iuentlj Biippnrale, 
necrosis of the entire thickue^i^ of tbe bone is blill more tbau probable ; 
though there may not be even an external wound. 

However ot'on-Moned, the wymplomB of coiupreasion from this cause 
differ very obviously from tho.^ prorluce-l by extravaaalion of blood. 
They are not of early oct^urrenee ; (iitrs, nnd Bometimes week^, elapse 
between tlieir ae<:eKsion anci the inflidion of the original iiijury. 
Whereas, compression by escajie of blotid is eilher immediate, or 
remove^l from the time of infliction "nly tu the extent of a few lioura, 
at the ulmoHt. Also, in the ciiac "f ubecces, the Hymptomaof comprte- 
Bion are invariixbly preceded by signs of the inflammatory process 
which cfiusea the suppuration. As regards ibe reMilt, the diffi^reiice is 
Btill more &Iriking. In compression by blisod, the extraviisati'in may 
cease, the blotxi is absorbed, and the braia recovers. Bui, in tom- 
presBJon by pus, the compresHing a^nl is ever on the increase ; the 
abscess cnlargts mora and more ; and pus is l»nt little amenable to 
flbsor[>tion. The bone is exrulijitin^, and, if it ivere spparate, the 
matter would doubtless fiuil an outward escape; but exfoliation is a 
tedious prticesa ; ere it has been accomplislied, the membraae, growing 
more and more tense, and itself involved in structural change, nJeer- 
ales, or filou;;'b*i ; purulent irnipiiou titkes pUicc inwards j arw! a more 
eitear^ive, acriuu^, and ODContmllaldc inflammation necessarily ensues. 
Or, previoiifi to the giving way of the dnra mat^r, a minor yet equally 
fatal inflammatory estension inwanis, by contfoiiiiy, may bare t>tcnrred. 
Or a sad compliciition may take place, by invasion of all tbt? sym|ilomfl 
of pyfemia. Or, independently of any such a^jgra vat ions, the primary 
evils of fever and eompiession may prove laiul. 

The symploiiis denoiiuj^ formaliun of this diingcroua abBcew are 
two-fold ', afi affecting^ the Evstem ; and ns iiffeeling the part. A man 
receives an injury of Che head, without fracture of the cranium. He 
may tindergo concussion, or compression by estravnsation ; one or 
otber, or both ; or he may not. If Ire dues so snfl'er, he rallies ; and, 
for B time, seems advflnoin^ favourably towanls complete lecovery. 
Hut, after Pomi^ days, he becuuies restless, wakefnlj and gtuetally un- 
oa*y ; his pul^ti rihos and gels hard \ the Bhin is hi ft and dry ; nod the 
other symptoms of infiammatory fever present themselves — moderate 
or intense, obscure or manifcBt, ai'cordirig as the inflammatory" process 
bappeuB to be elirouic or acate ; very freriuenlly it is the former. 
Fain is complained of iu the heajl ; the eyen change their expression ; 







a^'^1 



^rt^*j 



^"^r^ ly/ 



^, Ci^-^-C^r^Ou^ iCk^^,lA^ ^ 





Tif. 0. 



ABtiCESii OF THE DURA MATER. 

and ihe cerebral ftiQClioDs bogia lo eviace disorder. Rigor oocufB, 
aod U repeated- Siippuratian is begun ; and tlien Huperveae, more or 
leas rapidly, Uie sympluma of compreffiion — luafikm^, in Ibetr turn, 
those of llie inflainnjator^ character. Then, ae to the part. The boae 
is in a state of necposiH ; and this cnndilion will certainly he indicated 
exLernally. If ibere be a wonQd, the ^auulaUone, instead of preseut- 
ing the appear;ince of Leallh and he^g, will disapjiear, or become 
pule and gJsj^T ; and the illii- 
charge may for a lime cease — 

rehiruiiig thin, noJi- laudable, 

perbapn GangnineouH. If the 

pericranium Ije exposed, it will 

be ftiimtl scpariitin^ mon? and 

more from the bone beneath, with 

pHs interposed. If the bone be 

denuded, it will be found white, 

dry, BonoroiiB, n on -vascular — 

in fact, at first d>'ing, and 

Bpeedily dead. If the ecalp 

have not been divided eiiber by accident or by design, It J8 the 

seat of what ia termed *Mhc puffy tumour;*' a swelllog of greater 

or less extent, caused partly by accumuUliun of pua lurtwccn the 

necrosed bone and its pericranium, pnrtly by change of Btructure in tbo 

soft parts exteriorly, which are involved more or less in the eiteoding 

inflammatory prrieess, aod are consequently the seat of efrumon and 

exudiUion, Indeed, this '* puffy tamour," though a vjduable and 

peculiar sign of the iniemnl evil, is not to be regar-k-d as of a ti[)pcial 

nature ; being only the ordinary product of ripti inflammation ; ccdeuiA 

by wt^nini piipmally, infiltriition by filirinoaH i?xndiLtion more deeply, 

and ncenmulated pna overlaying the bone. 

These symptoms, lL>cal and eonstilulional, occurring together, 
denote intenor suppuration st the injured part. The local signs ''fol- 
lowing a smart blow on the head, and attended with languor, pain, 
reatloasness, vratching, quick pulse, headach, &nd elight irregidur 
Bhiverizigs, ito almost infallibly indicate an inflamed dura mater, and 
pus either forming' or formed between U and the craiiiutn."* 

Treatment. — The general principles applicable lo the treutmeut of 
abscei^ must be carried out, if poKsible^ The pan muat be evacuated 
esCernally ; and that at as early a period as possible ; as soon as we 
aro satisfied, by conjunction of the local and coaatitutional signs, tbdt 

• POTTt vul. L p. 41. 



Fig. G- Pluiij EIlLielrALlva uf uIihvdh iif i\k iIuta riiuti.T, a, iIk cnailum ; h, a jnippunUvd 
spu-e leTc by di?(ai:hEnral of Ibc clura ninEer; r. cljllo, hy ileyAtxitn itf llie iteni-rAiiiiiin -, 
h Abd c ixniBlitut*! thu centr*! space of iriie inflamniation ; J, (he arc of active fnugalion ; 
t, OiAt Iff sJmpli! ^■^riif'mtni ; r. d. r, I'finetitutiDg Poit'i pittfy tRimmr. 





34 



AB8CE9S Ur THK UCKA UATKK. 



matter Loft formed. TLe locul a^mploms alone are not a aufficieat 
warrunt for oper&tivti intt^rference; neither ftre tlie conatjlutionjil; but, 
wbeo they oonie togclber in a marked and pitun forni, the imrgean ia 
t;iU|iiibly iiL-^ligviil ^lifj iA~ii.]ihu](]i4 the trephine. By this iiiBlnmicDt — 
uhobon of a largti size, to make the |irobability all tbo grcal^r of dia- 
cloBing the suppurated pmrt — the dead portioD of bone is perforated ; 
and then the abscesa is dihchaiged externally, with immediate rehef to 
the Eymplocis uf ccniprct^i^ion. iJe it remembered, however, tliat those 
of inflammatiuD s(iU remaiiL, {>orhaps ag^-avated by the addition whit^h 
the iojiiry of ibe opcraliun bcui ocoofiioDed. Antiphlogistic^ must still 
he (;outiuu4nl ', and much c&r^ful iuai]ag«]ni!iit is required, cv(?ii in tile 
moGt favourable cases^ ere the patient is conducted to Bofe completion 
of the oure. It may happen tb^t the inflammation ia not checked; 
but, tipreading both widely and in depth, provea ultimately fatal. In 
abort, while it in obvious that the only chance of the patient's safety 
ia by artJIicial evacuation of the matter, it is c<^ually plam that the 
oj>erflti<->n alon« will not Buffice, but must bo followed up by the moat 
careful general treatment. 

It kis happened that the absceae, burrowing between ihe dura 
mater and hone, has eveittuully reached the internal ear, and diAcharged 
itself extenially by the meatna ; the palieat recovering- Bui, ohvioufily, 
uuch nu occurrcuec is a rare exception lu a general rule, and cannot Ixj 
lrufili:d to in praclice. 

If, on removing a portion of skull by the trephine, mattLir is not 
fuuinl, a question arises vhollKT our efforts at direct relief are to 
ceasQ, or wtietlier further exploration is to be attempted. Is the dnra 
muter to be perforated, iu the hojjf that the site of absccKti may prove 
to bo beneath ? Nol, if the tnembrnne present ita usual normal cbarac- 
tern a-t the part exiwaed ; levtsl, moving KjnehronouBly with the cere- 
bral mi\A&t smuotli, of a bro^vnisli hue, and showing Gomething of a 
hilvery biKtre. But if it be protrudinjLf tbrough the cnuiial aperture, 
tioeciilent, non-pulsating^, und either loo <lark or too piile in colour — and, 
more especially, if it afford unylliing of a fetling of fluciuntiou when 
touched — 'Wc need nut hcBilatc to puncture, uud need not diiobt tu find 
an issue of purulent or other fluid from the wound. If the dura mater 
appear bound, and its puncmre conaecjuenlly be unwarrantable, are we 
permitted to reapply the trephine; either at the site of contrecoupj or 
in the immediate vicinily of the first appliealioii? Either of these 
pn)OtdureH may Imj warranlahle, if the bynipLoms of dnra-ujiilrul abbccfiS 
are pectdiarly marked, und the &urg4<on is thoroughly convinced of itB 
uxistuncif. But, as 4<an readily be understood, the latter Mie of renp- 
plication in the preferable. Aiid, as already state<l, a large size of 
trepliiue Bhould be employed at first, to anticipate the neceeaity of sudi 
repetition. Only in very extreme coses, should the site of contrecoup 
bo trupUined. Haviog failed in the indicated spot, we procued to 
Other eiploratmnn with jjreat unoeriaiaty. Fmtunutely, buwever, it 



ABSCKS3 OF THE Vn&A UATEK. 



35 



I 



is couip:^rutive1y tieUom that the Bito of abfoess ie cWwbtire tbjui a( 
the injnreil part. 

But, if the c*se be under our cr^iKunce from the first, we have a 
higher ^m thftn Lhe mere eserci^ of our art hy operation ; seeking Lu 
prevent the fonnatjon of ahscei«ST not to attempt txs cure. The palieii L 
who has Biislfcied ao injury uf lhe beftrJ, uf B-ny aeverily, \s carefully 
ivatGhod throughout tho whola period uf coiiTaleeci-'ncc ; and tho Gret 
HymptomA of InilatnTnfttnTy nrc^ssion within the cranium are met hy 
Hctive aid suHtdincU nntipbJogisttcB — more espBciatly blood-letting, 
quietude, avoidance of all stimuli of hoth p&rt mod eystem, low diet, 
pargatives, and parhaim calomel ; affliEtted, if need be, after a time, by 
counter-irriiatioii* 

WbtfU suppuration ha^ taken place cither in the substance of the 
brain or on itt^ Hurface^ tite case h obviously nut amenable to direct 
mrgical iulerfereoce, and may scarcely fail to pn)ve fatal- Cure is 
beyond our reach ; but prevention waj3 not> And the latter indicalion 
sliiiuld sufficiently occupy our regard in the previous treatment of the 
injury- 

When a eevere scalp wound baa been Buatained, with bniiaing or 
fissure of the hone, it is not uncommon for the character of the wound 
to degenerate as m the ca^ of dura-matral abtcess, with some constitu- 
tional disturbance of an unpleasant character. But neither lhe meu- 
in^tic fiymptome, nor thoae of ci>rDproBaion, appear, Suppurntion hoti 
taken plfice in the diploe If figure exi^t— imrhnps extending only 
through tho eilemal table — puB will be found slowly oozing out- 
wards- Enlargement of the cinuk is neceseary, however, for more 
free evacnOition. If there have been no previous Bohilion of continuity, 
the trephiue may be use*l for removal uf a {fortiou of the t^xlerual 
table. 

The mir?chief may extend inwardly, and dura-malral abscess form, 
a» previonsly ttate^l ; but, fortunately, such is by no meani* the invari- 
able result; and is indeed tittle hkely to take place, if suitable treat- 
ment Lave tieen a<iojded. 

If phlebitis occur in the deploP, lhe <^afie liecomes eminently Beriona; 
partly on ocoonnt of the direct effcct£ of this diouose { but mainly firom 
the risk of pyntmia. 

After iDJuries of the liead, abscess of the liver is by no means 
uttcommon; and it is probable that si leaBt many of iheec cases are 
connected with unhealthy suppuratloiif with phlebitis, In the diplocf. 

Fractures oftAe Cranium, 

In the child, much violence tnay be sitKtained bytbo cranium wJLli 
Impunity. Tbe osseous (isffne Sb ^en elaatic; it yields to the force. 




36 FHAGTUKES OF IHE CHANIUH. 

and u tctDpuruiU dfpr^ssed, but wiibont nolulion of ixe coulinultj ; 
And, &f)er a tim«, tlie d^prefleiori la grAdnally effiLced \>y a vital 
reinliecice. iiid^»enderl of externa! aid. In llie adult, and Diore 
r6f)e>cuHv the Jt^d, iIjo bone is of n mDcli more briulc nature ; and 
less firce sncceeds in effecting solution of continuity, more or lese 
eilenaiv*. 

The fkull uittj be merely fiesured; or llie injured part b broken 
iDti> EragmeDtfi, implicalin^ the nhole thiobne«s o^ tbe bone, with or 
without depressiijti of these : or the external table a^one is broken ; or 
the uitemal table esclusively anffcrH; or both are penetrated by a 
ebarp-pointed ^ejij^on^ tLe internal Biistainiug the greater amonnt of 
injury. The fracture may be at noy part of the periphery of the 
cranium, or m^y traverse its b&se ; and, further, it may be either 
rampte or eompound- 

The dangers attendant on the injury are Tarions. L By concus- 
sion, 2. By extra vasal iiin of hl*)od wJtliin the craniiini, 3. By escefl- 
sivo escape of blood externally fnim ilie wound. 4. By dispUiceinent 
of the fractured portions inwards, t-ausing compression. 5. By inflam- 
mation, oeciirria^ in either the brain or its meciibrancfl. 

Thi^ Iivniaienf v.\\\ camYtnAe various indications calonl&ted to 
oppose these several results. 

Fractures of the tranium, whether simple or compound, unite only 
by definitive callus. Want of provisional calhis, doabllfiSB, may delay 
completion of the healing process ; but all incommodiog of llie brain or 
its membrauea, by oaacous bulging, is avoided — which olherwi&e could 
Tiot fail to oi^ur. 

Fissure. 

Capillary solution of contiQuity io, in itself, a thing of but little 
importanc'e. But the shock which has cau^d it may weU occupy oiu- 
aJlontivo regard. The fiEsuro itself^ indeed, may in iln f^jrmation bn.ve 
proved an actual iwlvantage; rendering- tbs foncu&^ion le;^ intenKP and 
less hazardous than it might hnve beeti, had the ringing calvarium 
remained entire. 

TLe litisure may be short, and bounded by suture; or it may 
traverse several of thesEf and be of great extent. It may take place 
at the part strntk, or at the site of the <^o7itrei^oup. It mity be con- 
joined, or not, with mpture of the dura maler at tlift fissured part ; and 
if it be so conjoined, compression by extravasalion is likely lo ensue, 
^Vllen the injury is atuatc at th« base of the crauimn, it is usually 
associated with such rupture ; and extravasation occurring at this Bite, 
even lo a aiigbt extent, we have already seen lo be of the gravest 
import. 

The Byniptoms attendant on fissure are uaually those of eoncnsnion, 
in the first instance; and these may be followed by those of compres- 
sion by extravasation. Infiamtuatory accession hi not unlikely ; giving 



FISSURE AT TUE BASE OP TRK CRANIUM, 37 

the ordiTinry train of symptoinRT varying act^Drding to the part and 
teiture involved. And these, again, may be merged in lie eymptotQ* 
-of compression by suppuration. If the injnry le compound, the 
exialence of fissare is ascerlained by tlie finger or iirohe. If it l>e 
eimple, the fissure may very jjr(fl;ibly elude detection ; the case luring 
treated as one of fiimplo cnncnpeion. 

l^ng aoTLi, it was tho cnttoni^ in the treatraent of tin's ijgnry, to 
expose the fissure throupbout ils whole extent, by inciFion ; and to 
apply the tre|»hine rc"peati?dly in iUeonrse; probably in the hoiie of 
liberating extrava-saled blood. But no oiib now Ihinke of thus aggra- 
vatiag whiLt ih in ilneU compiiratively simple. It ih time enoityh to 
tako np the trepbioci when nymptA^ras of coiuprpHaiun, by bIcHjd or by 
pnH, are nn plain nr\<\ ho urgent ah to demand its iiho. It Ls not ofteD, 
as already explained, that on the firh-t eount we are called upon to 
operate^ and, if we have seen the ca«e from the GrHt, it may be our 
own fmilt if we have ht interfere on account of the untoward result of 
inflHiumation, The treatment is chiefly eApectaut. We await resiction 
from tbo effecln of cououesion; watch the period when extravasation in 
likely to occur; and, iT need be, then interfere — repressingly. That 
period of dan^r havintr passed, we are a^nin qniesceut* tbouj^h alert; 
]i»okin^ out for syirtptoma of iiiRamiiiatory acocsfiion ; aod ready U\ 
oppose these with energy, should they appenr^ 

Fissure at the hose of the Cranium. 

^lution of continuity, in this situation, is nsually a GsEiire; dis- 
ruption, more or less extensive, without comminution or displacement* 
The fiesiire may eitljer e?^tond lhrona:li previonsiy compact bone ; or be 
a kind of diastasis — peparatioo of the f^phenoid fr<jni tho temporal 
bonfB^ for pxampk', at the orij;nnal poinls of union. A*i fdready stated, 
it is generally accompanied widi heeralion of the dura m^ter, and 
internal hemorrhrige ; and consequenlly is invariably attended with the 
greatest danger In life- The important j)arla of the train iujplicaled 
are almost certain to be compromised in iunclion^ &>oner or later; 
either almost immediately by cxtravitwition \ or by inflammation at a 
more rerrmte p(?Hod. 

I'he injury inay be occBBJoned in variouB ways. The head may 
be cnjshed lalendly ; aa by being jammed between a wheel and a wall 
or post. Or, while the body ia at rest, a severe blow is received on 
the vertex J and the btrain of the shock, communicated through the 
temporal bones, praduocs a splitllng of thcfic^ or tears open the con- 
nexions with l)ie RphenoifL* Or the body^ falling, alighls on the 

* " If a fierce b« Applied to the v«Ttvjt, tfa« Auperior border of lUfl parietal bones r«9l»t 
dUpUcqfflcnt dp wn wards, uidamucb u llitir [tircnur IwnlerB canEint 1« ihruh'ii utlIvfuiIi 
la oHiMqucnfe of their bping sup^nrrted Uterjilly by the oyerljippitig of the aqannioM 
partioofl nf tbe tempnral ]>onM; vrhilb Che tamporHl bono, n^ ^[. Malgaigne ba^ puinled 











as PUStmS AT THE BASK OP THK CBANTUU. 

r«rtex; *nd Ae signal column, cwrring both the weigfbt nod mometi- 
loiD of Ibe bodr. is drirea dr»wii upon ilie cranial base— tbo bn^ilar 
pffOectt being probably bn^ken through. Or, felUng from a heigbl, 
the i^ieiLt »ligUts on bb breet:b, or ™ kia Ijeek ; and, again, a lou- 
cQEsiao safficieot fijr diampliun mai^ be so commnnicaled to tlxe cranial 
baw- Tbe eilraTisation is nol alvrays alight ; il laaj be great, one or 
more of the lar^ vfooiis anuses having been lom ; tben the symptoms 
are &vm ibe firal moss grave, and cannot but end falaily and soon. 

The circnuistancea which Ica/i to a suftpictfu of fracture at tbe 
baw of ibt akoU are : The kind of "ijury inflicled, s\icb as abeady 

described ; Rvniphime of CMnpres- 
KOD, early and aevere ; escape of 
blood from the ears, nose, moutb; 
ecchymo^s of Ihe eyeliils and 
ocular conjunctiva ;* and difi- 
cbat^ of a watery fluid from the 
^^ ear, sometimes in considerable 

^.*iCl f^ \ S^y^ld- " ^^^i abundance. Tbe last symplom — 

iifleu termed ** weUing of tbe ear" 
— \& Dot immediate, but occurs 
af^ei some dayn have elapeed' £y 
^^^^^fc^fc.j'1 tn some it is ocmsidefed to denoTe 
*** t.^' -, 'Ktn^^^H^^^^V V / escape of eerous dui<l from the sac 
^**^'\V*^ V f^^K^^ ' / of the arachnoid: others, contend- 
jIm^ ^\\ ^^m"^/ L^^ \i ing that the phenomenon has been 
(J^^-^Nl ^^J-'tZ^ / knoTFU to occur when certainly 

^ " ' that sac waa not opened intc^ be- 

lieve that th« 6iiid is but tiie 
serum of extravnsaled blood, trick- 
ling ihroug^h the fissure ; by all it 
^^-"^^ IS held as a eijii of moet unto- 

wmnl import,^ BJevding from the noee, month, or ear, following on 
■DTT-re iqjarr ^ the bi>Ad, is alnraj^s enspcions ; wore eapecially if tbo 




■ml, u* ihmwJrvfl fH|ipoc1rd T^r lb* ivp^mt, vhicb cooBFJnitH on curb eidft A tmfl 
ItttllriTW, ^vMuonl ^v ibr «u)v[ii>r nuim*n' bom^ Asbwk, then, npiilitil lu llic xiiitciL, 
hi JiTKtty rrukuniRnI t.i l>* traii^^ral hon* , And pTf*|iA^ro>l tJirouph it* prlrom parlEtuiB 
*p tbw p»wl<Ti*'* p*rt v^ tb* body irf tbe fphenntJ bonfl» the par»* whict njost frtcturps of 
Uw («#» tif Uv rruiQw Uat«rWv~— BttL 11ml (or- U«L Rfv. No. ^, p. 174. 

* Tb« iirt>itit] ptot«H bariiig bean brnk'u liii\ und IJntMl mlilTradag fonvdrda loto tb« 

t lwi(M^ AnMw Gnunhv, A«il, ]9«A; jiLw, Bril. And Fiir. M?d. Chb, R(>r 

ttu.t«a^ 



F1^ T- Kltmrr ■! (b* bk«« ^f (Ilp tkull. iiii-tiKin^ tbi* acv-L|iIijI and ^pbi-aoid booei. 
TW Ipaiifvl fUl (tN^ni k \tMv\ <mv lh« vcrtox, nthl Lh)- iMuuttiw far Mntc davii bcAn 
4MMlk lUtMW^ P«iravHKU>n w*i iDaml otw tb« ^^^ImUuui lad ukldk lobes of the 



%^ ia«.&A^ 









rRACTPRE WITBOCT DISPLACEKEKT. 



sa 



patient te funnd in a state of insen^bility. But let it be bume in min<l 
tliat euch a combinaUun of circumstances by no means certainly 
denotes tlic exLstenc« of fracture at tbe ba^e ; the LUfleniubility may l« 
that of concuRiion or of Jnloxication ; liie blerdirjg may procfe'] frum 
mere laceration of tbo Eohncideri&D TDombrano and of tbe limng of the 
meatus ^^^^ ^^^ injury of the longiie by ttie teeth. When, howevpr, 
we have Bdcb bleeditig;^ accompanied by urgent insensibilitT, obrinuitly 
of tlie ralnre of coma ; when the bead flymplums eiTher remain unim- 
proved, or advance untowardiy ; and, more eaiiecidliy, when by and by 
the " wtlliiig of tbe ear" ainwar» — we may eafely conclude that frac- 
ture at the bA^ has ocenrred. 

Tbe treatment mnst plainly be prophylactic and expectant, » 
already advised in tbe case of compression by inaccessible estravaaa- 
tion. There is no room for direct operative interference. If the com- 
preKaion \te happily got over, we must then be very walchfiil of inflam- 
matory ftcofsaion. In all cascB, prognosift i* nnlavourable ; ihe majority 
prove ffit^l — either immediately by coma from eitravoAation, or more 
remotely from tb^ efleeta of inflammaliun. 

But it must be remembered, I bnt fl»;Bure of tbe cranial baM mfty 
occur without any characteristic fiymptoma being evinced ; tbe patient 
seeming to labour under mere concuBsion. Tbe li»enre may have Ijeen 
slight ; au4 the WuLi'iri of c^mtlriuiiy itiay have been conflni'd to tbe 
boas alone. Tbe membranefi remain entire; and there la no inward 
escape of blood. 0>mppesEinn, by cxIravasiLti'in, necejiaarily (1i»en not 
supervene; and inflammatory dan^r may be warded off by ordinary 
care, Snch cju^ea, however, are of comparatively rare occurrence. 



Fracture inihtiut Displaa^ment. 

Tbe most common solutJon of continnity in the cranium is not a 
mere fifieure; but a fracture, analogous to comminuted fracture of the 
lung bones; rediu^mg the injured part to tbe condition of being bmken 
up into one or more fragments; and tbeee may or may not be dia- 
placed. When tbere is no displacement, the dangeis to be apprehended 
are eneh as are common to other injnries of the head, apparently lem 
nevere; eoncUBsicn ; esccesaive reaction, bringing compretwion either 
by extravaeatian or by untoward inflammation ; or a more fnnidious 
inflammatory process, occnrring at a more remote period- The frac- 
ture may be simple, or compound, or with wound. The compound is 
neceiearily of a more uulavourable cbaracter than the otbere; danger 
by inflammation being greater and more probablC' But the diflferencc 
IB, on tbe whole, not so marked aa between eorrpsponding injuries of 
tbe bones of tbe extremities. It is possible that the existence of a 
communicating wound may prove even an a'tvaiitage; by permittinjj 
outward escape of inflammatory or other effusions, and so Baving Ihe 
Important internal parts. 





4<) FRACTDRE WITS DISPLACEMENT. 

The tTeatment is propbylacdc and eiiM!ctant ; acctuding to Ihe 
n;enerftl jirinciples already explained. TLere is as little oeceBeJty for 
immedia-te trephining, ih in the case of mere fij^aure. If Ibe injury 
liavt l>een aaslabied at the li>wer and anterior angle of the parietal 
lione, and is speedily followed by urgent com pretBion, it may be advis- 
able to apply tlie trephine in ordi^T lo afford a freer vent for the 
moningfifll hemorrhiige. But, usnallv, ihe aperture already existing ia 
siifiitiieut for au oulwanl drain. And again, shonld eympiuois of 
oompression by snppi]ratic>]i RU{>enenei at a mi^re advanced periodj 
njieralivc interference may be neceseary to efltct a free eTatuftlion. 
Ill genernl, however, tbere is no neceBsty for the uen of the trepUine. 

Fra<iirre leith Dtapltvem^ni. 

If tho fractured portion, or portions, be tJigptaced inwards, the 
hrain \a more or le^H i1lcom^J1Klt^lT und tsymptoniH of e^rmpreasion 
ensile; proporlioned ntaiully to the ansonut of doprcRSlon, and to th« 

rt-'lative importance of thnt part of the braiii which ii injured. The 
upper and anterior snrfjice of the brain, hs formerly slated, may bear 
a very coiisidt-rablo amount of coinpression with comparative impnnity. 

The tiyury may ot'cnr without corretponding wound of the soft 
partji p biit usually (he frnolure Lrs eompotuid. 

Thi? dimgers are formitlable. 1. Ky conpuesion, 2. By extra^a- 
Rntion of blooil. 3^ By llie rir^EillF; of i]if|ainni;itton on che brain and 
its membrauea. -t. By compret^ion, Ciiiaed by the displacement. 

The three first are to be op|*(ised by fulfilment of the ordinary 
indications. The Inst is to be removed by operative iutprferenco. 
But iti regard to ibis the question at onee arisen: — Wiietlier, in all 
easc'H of dopretHtul fractnrc, opi^ralivo intorfifronut', for the purpose »f 
repifteiug the depressed porlion of bone, is iieceiisarily domanded ? 
Formerly, the auawer wan in the affirmative; at presenl, it ib not bo. 
Klevation of the depressed ^wrtiijn is ha*l reconrse to, with two reme- 
dial objects in view ; to remove the cause of compreHbion, aud conse- 
ipieutly llie symjiloms of this, wUen tLey esist; and al&> lo remove a 
likoly exciting cause of infiaiuLniilion from the portion uf cerebral tiBBue 
and mombranptt acted «puu by llie ilepresyed luine. When the symp- 
toTiia of compreKsion are great aud urgent, there is go room for heaila- 
tion; it is pkiidy the duty of the surgeon at once to attempt removal 
of the cause ; and fulfilment of the furioer of the two indiL-ations is 
BidlicieiiL warrant for recourse to the operation- But if Aymptoms of 
comprcBbion eithor do not exiftt, or are sligbt, and arc reccdent ratbcr 
thai] gtavescent, tho case is very different. If we operate then, it is 
only lo fidlil Ihe bitter indicnttion; removal of the exciting cause of 
WW nppicbended iiiflnnimatory process. And then this other question 
arisi'ji: — Whether the conlimud pressure of a , smooth portion of de- 
prcHcd bone, or the injury inflicted by performance of the o^ieration, 




FFACTUliE WITH L>ISPLACEHEKT, 



41 



i 



is the more likely to excite an niitoward amoimt of tliis? Experience 
has answered to the etfecl, that the greater risk la eooouiilered ly 
recourse to operatioii.* Acd» ctmsequnntly, the rule is, to rtfraiu 
from operation in all caEea of ordinary depreE^sed fracture, [□ which 
BjmpLouis of compression dn not exist. Further : we know that tlie 
brain has the poweT of filowly recovering ujider a ^-erlain ftraoaut of 
pressure^ even when that pressure ciintimioii imdiminifllied. And, 
consequently, the nilo of Qi>u-interfereuce in extended also to those 
cases i[L wliicL tlie Hyiaptoma of compresBion exist, hnt are hy no 
means iirgpnt, and seem to tie slowly reueding railier Iban on the 
incronae. In yonng Bnbjecis, tLe call for artificial elevation must be 
especially urgetit before it oiui wilh propriety be obeyi^d. For in them, 
it is to be reuienibered. a system of mutual arcommodalion may be 
said to he in pro;^eas; the brain not only becoming accustomed to itfi 
altered tircumstaiict^s, but the compreBsing agent, being also gradu:illy 
wilhdrais-n — the bone, by its iuiit:rent ehisiicity, slowly re- approaching 
its former level. In the aiiult, there ia n^ft ihe same resiliency ; but 
then too eometbing is done^ "" the jiart of the bone, to favour complete 
recovery of the functions of the incommoded organ. For after Home 
considerable time, the depresBed portion iw found to have become won- 
derfully smoi^th on its inlerual surface, and bevelled at its marginn, by 
absori>tion; not ceasing to press, but now pressing with all genilenoBa 

on the part» beneath- 

In ordinary fracture with die placement, therefore, wo do not initr- 
fere by operation- unless eympturns of compression not only exist, but 
are urgent. And in these caaea tlie operaticm may not wholly succceil ; 
the tompression being perhaps by blood as well iis by bo^e. In all 
other cases, we content onraelves with the expectant aijU prophylactic 

treulmeiil, an tf di^preasiou did [io[ c^Liat. 

When the fracture is comjMJund, eomminuted, and depres&ed' — that 
is, when fragraeiits are not only displaced, hut comjfletely detached 
from the rest of the cranium — we of coarse do not hesitate, in all 
sncb cases, to remove the loose fragments, with genllencBs and care, 
whether symptoms of compression e:4ist or not. 

Also, let it he utideraloo-l, that when, in a caae of compound frac- 
ture, with dit^jdacemeol, sharp fragmenta seem to be daugerouhly in 
contact with the dnni mater — much more, if this membrane be pene- 
trated or prmctured by iheui — we ought at* soon as possible to raise or 
remove the offending portions, whether head symptoms exist or not; 
for in no other way <:an violent inflammatory acceBshm be averted. 

* Abundnnce o{ i-^rv* nn on rctnrdf I<^stifying llio puwor nliii'h the Etmin haa in 
bevniL^ long-CD Dtiaui.'d pn'^Mire, iviLh coiDiaraliv? impunity, po for as iDflfunuLdlnry 
ncvesabn is coneeratd. One very rcmflrtsal>lp ijintancc h reljilod hy Sir A- Cooper 
(Lectnraa, p. 128), in wlnuh certain f^tJiptoais uf touijjrfajiiiii] tndurerl fur ii|>w»rclfl of 
tliirb^TTi luumliSi lu lUuHqueiiFu uf lUt cxifiUiULi? ^r ilF|jiT^3etl frm'turcj compluto and 
ahnodt iujtant remrciy futlowini; mnoval nf the dcpresaioD by opemiJon at Ltu- vnii of 
that perl Oil. 




42 



PDNCrnBID FBACTURE. 



When opemtive interference is determined on, the indioationB to 
be fulfilled are fiuflicienlly plain. To expose tbe parta, by suitable in- 
cision of the soft LextTirefi superimpoeed. To use tiie sound m&rgin of 
boue 03 ft fulcrum, on wliicli iho elevuling lever may rest. To hia- 
nuiito tbo extremity of tho lovor bt^ucath tho displM:cd pnrt, and to 
effect replacement with as little violen^'e aa iwseilile. For the insar- 
tion atjil working of the elevaturj sufficient space may alTcmly exisL 
If not, this ifl to be ac<inired ; by genlly lifting away a loose fragment; 
or by removing a portion of the sound bono, by meanB either of the 
saw or of Lhe trephine. AAer the operation, much antiphtogi&tic care 
muBt ocecBBdrily he DtaintaiDeJ. 

Punctured Fracture. 

By the term "ordinnry fractine, with or wilhont liisplacement," is 
meaui injnry done by an obtuse botly; causing solution of coniinnity 
Ibroughont the whole thicktippn of the bene ; and prodoning frogmentH 
ouiupoeed uf both tables of the sknll, <^pa.ra[ed fram th^ir ^n^ral oon- 

nesion in nearly etpittl proportionB- 
A smooth, uniform, non-jjcnetraiing, 
/^■^^p. surface is consequenLly preKented by 

the depresaed portion to the brain 
and itti mcmbrauofi. But when a 
sharp - pointeil Buhstimce — as the 
point of a poker or pitchfork, the 
corner of a spade, shovel, or hojumer, 
or the angle of a sharp stone — im- 
pinges on and jienetrates the cranium, 
*' the nature of the injiirv i.s very difle- 

rpnt. The BTtemal table is cruahed by the penetrating body, to an 
extent pr(Tporlionate to its loilginent. But the inner table, being 
much mure brittU', gives way to a greater extent. It is broken up 
into fragments — luujtlly small and Rpiculated — \vhich, being driven 
inwards by the force of tho blow, penelralc, or at least seriously irri- 
tate tho coveringn of tho brain, producing inflttmmalion* Thia raay 
\m3 grneral, involving the braifi itself, and to tho last dpgri^G danger- 
ons ; or it may bo limited to tho injured dura mater* causing abscess 
there — a resnlt slin must perilous to life. And to ai'complish tho 
bitter evil, it is not noceswary thut the fragments ol tiie inner table 
should i>enotrftle, or in any way mechanically injure the dura mater. 
It if miEoicnt Ihoi tlii-y are JisUichcd from iho general cranium, and 
MDun uimaiovod ; tlieu tht^y neeossnrily dio ; and, as bequr^stra, they 
InovitHbly Wome snrroundesl by |inndcnt formation. 

Tho ndt? of practice, then, comes to be plain. Whenever we are 

F1|E< ^ Punclvml fhuturr, ■( n; nt 6, the dan niilCT repn-KDleiL deta^bnli nM 







PUbCTDBEU FBACTDRK, 



43 



flfltiflfiiMl that pniii^tiired frnctnre lias occiirrerl — f n rtthpr words, ttat the 
kind i'i fnu:turc is such lliat sfiHutenng of the internal table la certain 
— we cjinnot too ftoon pn^ceed to operation. We trephine immediately, 
80 as to expose the frogmentSi iitid admit of their being carefu]!/ and 
efficiently removed. Unless Ihey are taken away, antiphlogtstics are 
pTTkctiscd in rain ; iD^funniatioti bcootnca cfltabli&hi^d nt iho parf ; 
sooner or laler nbeoeas funnn ; ari't lb*?n we find otimplvps cottip^lled to 

operate for relief i*f oompretsed brain, under very iiufavourable circnm- 
atancefi. The least refnilt is abscoc^ of the dura TQater ; but it may he, 
that even the questionable chance by ojteration ia nut afforded, the 
inflammation having prove^l general — cerebral, as well ae tneniugitJc 
— and qietdil^ canyjng off the paliciiL Taking the most bopcfijl 
view of the ookp, a. nere^wity for ojicratJoti ir f^ertuiiL to ariM^, at Kome 
stage. And surely it im most prudent Co operate al that time which 
plainly is most promising of an auspicious residt- Belter to operate at 
OQce, removiikg: tlie paramount exciting cause of the infianimatory pro- 
cess, and probably averting all caanalticfl ; than lo attempif ^ubee' 
quently, to retrieve or limit danger and dtaaflterf alrcadr EDflt&incd. 

The rule as to operation, then, is very different in the case rif pntic- 
tured fracture, from what is applicable to any other injury, hitherto 
considered. We at once proceed to the operation of Irephining, 
whether head symptomft are present or not. The mere existence of 
this form of injury is an amply sufficieDt warrant for oar interference. 
Heo^ nyta^toiBS^ ^ad thijae of a tnoat urgent kind, are certain to miper- 
vene, if the operation be withheld ; and they can be averted only by 
early removal of the splintered fra^mienls rc^tin^ on the dura mater. 
After the operation, antiphlogJBtic treatment must be se<luloualy main- 
tained. 

Ah in the case <jf concussion, it may be difBculi, at first, to per- 
sutide the patient — oa yet Buffering but little — of the propriety of 
instantly Bubmitting to treatment which may seem lo him unnecca- 
sarily severe, and indeed quite nn warrantable. Thia obstacle ia t£» be 
overcome, by a calm yet earnest exposition of the certain danger which 
other wiw awaits him. 

Obviously, it is nur finl duty to cume Lo a juEt concluaioD as to 
the existence or not i>f this kind of fracture. A most minute exjUDinB- 
tion is flcnordingly rra^Ie. The *calp is freely divided, if need bp, to 
expose the fractiired point to nght as well as touch ; and by a gentle 
yet determined use of the finger and probe, we endeavour to aatisfy 
ourselves thoron^ly; assisted in our decinon by regard to the mode 
in which the injury has been inflicted, 

Penetrating ctrta of the Cranium — aa by a aabre, axe, or sharp epade, 
— often clo&ely resemble puncture<l fracture, as to the kind of injury don« 
to the inner table, and the immediate necessity for operation. When 
the cut passes sheer through botb tables, the bncr one is Ui^Lalty splin- 
tered; and the tragments press inwards, nntowardly. TLey must bo 




44 



KFEALTUftE OF THE EXTERNAL TABLE- 



removed. Tho cLiLsm of the wound is often sufficient to disclose their 
prpseuee aod site, to fiiiger or probo ; and it inu,y aiiffiue for removal 
also. If notj room is to be made by applicitiun of Ihe trepbine, or 
saw, as may seem most convenient. 

Fracture of the Extet^al Table, atone. 

This 18 not an uncommon resuU i»f comparatively slight viii^ence 
di>ne to the cELlvariiim ; by bodices either sharp or obtuse. The px- 
ttrmil table alone gives Wiiy ; and is perhaps driven inwards on the 
diplcc. Tlic most marked Eitniplc of the injury is affoi'dcd by frjictura 
over th(> frontal ^iniis ; in otWr parts of the cs-lvarinm th<^ acddeat 
occurs only in ibose of middle age^ who possess diploe, with marked 
distinction between the cranial plates. No operative inlerfL-rence is 
required; escepl in the cai^e <jf the frontal eiiuiE; and then elevation 
of Ibe depressed pijrl is expedient. The treaEuient Ls, locally and 

generally, antiphlogialic. But, aa formerly atated, tht^ iufiaiiiiufttory 
pnw^BS may become i^seessiv^", and eitetid inwards; and Bi]p]iuratioii 
in the diplo^ may lead to siippur&lLon al^o on the inteinal nspecl of the 
bone, neeroNis of the implicated part ensuing. Under such circum- 
Btances, the operation of ti'ppliiniiig iti likely to be required, to ndieve 
compression. SameLimes diikliiai phlebitis, with its sad consequences, 
eneuee ; too often baffling all treatment. 

Fraclnre of tht Tmier TabJc^ ahme. 

Fortunately this is of comparatively rare occurrence ; for, the outer 
table remaining entire^ we bare ro Eicans of aecertatuing the naUire of 
tho ii>jury, at the lime of inilictiun. It may fLjlhi\\ nw jl ^llarp cunciis- 
sing- blow ; ill a p:itient, who, by reuson of age or other cau'ie, baa a 
vitretms table of unusual briltlenesa. The lable uuiy be simply severed, 
and not mueh depressed ; then bead symptoms are likely to prove 
both slig'ht and transient. But, more probably, there is comminution 
as well as displacement^ and then the xisnal hazard is incurred from 
tbe UeprcBsed iiod perhaps penetrating spicala. The trephine la likely 
to he oalled for, after a tme, on account of dura-matral abscesB. 



Depression without Fracture. 

As alrewly stated, tliia occurs only in children; in whom bones 
are more prone Lo bend tlian lo bre;:tk, A dimple Ie ina<le iu the 
sttill by esternal violence, and iE slowly effatcd by \'jrlue of tbe in- 
herent elaalirity of the tiasiie. For a time, tbere may be Bymplcms of 
compressioD ; biit seldom of a marked cbameter ; and siill more rarely 
urgent. Operative interference is neither necessary nor expedient. 
Tho treatment is simply aiitiphlo^5tic ; and prophylaxis is long main- 
tained. 




OPKRATION OF TBEPUISINO, 



4fi 



The Operation of Trephiiung. 

The treitUine ia a circular saw, workej by a light ftud rapid move- 
mertt of tlkG band, vrhertby a poriion of lliu skull \s itivitlod, nxid may 
be renkoved. For iu applii^atioiif complete ex[x>suTO of the bone ia 
oecettary. If a uaaiid already exist, it \& (.'idurged lo Lhe necessAry 
extent. If ihere lie no previm^s wound, u crucial or other inciMon 1b 
moile; &o tbat, by retlectina c*f flaps, the required exposure maybe 
effected. The pericrjinmm ia cjuefiilly niised lo an exieni sufficient 
tu Admit of the free pliiy of the inslrunient; but ni> fjiriher. Tbe 
(*n(je-pin, sbarp-pHnfed, havin^r been tottdc to protrude a sborf way 
beyond the serrated edge, is securely fixed tliere by ila serew. And 
iben, by Srm preseure, aceoiupanied with a tlji^ht rotatory ntolion, the 
centre-pin is fixed in the Iwjnej so as to slpwdy tbt* inHtrument in ite 
Grsl mivemeota nn the exk-rnal Iiible. The tt'itii ijf tlie Irephinc are 
nniAlly hcI ro its lo work from left to right j iloJ it tu waW to h.ivo the 
ermrn fluted on ita lower balf — this bein^ foiir^d to favour ita free 
play- Tiie tiimlnEw are madfe steadily and rapidly ; with very light 
pretsore, after tbe cei>tre-pin has been fixed ; and the lipbt ].re&Bore ia 
exerted only during tlw movement fr^m left to right. When the sulcus 
has fulviiiiced to buch u depth as ]& ^cinj<;ieut I<r retain tbe saw bteady 
in tbe gi^hove, tbe instrument ifl withdrawn, and the cvolro-pin poBhod 
back entirely ; lo proi.-eed with it ptill protrndinj^, were not ^^x\\y lo do 
what is nniieceasary^ but also to eucoiniter much risk of injury to the 
dura mater at the luLler part of the operation. Tbe plain crown ie 
reapplied, and worked etea^lily as before. There is no occasion for 
burry ; the operation ilself, Hu far as the sawing of Uie l>one ia coucorued, 
fe comparatively pninleps; lieeidow, it ia uaoally undcHakcn while the 
patient is insensible; and in those cases nhere •lensibility remmns, 
eiperienco has &hown that ona^Rthesia by chlomform may be practised 
with peifect safely. If diploe esiat, a cbange of sound and feeling is 
imparted to the ojierator, intimating tbat the saw has passed the 
ejttentui table. Then tbe instnmient i* wurked ver)- warily; and it 
18 well to rcTiiove it from time to time, examining the sukas wilh a 
probe or louihpick, lo ascertiiin wbetber or not at any piiint Mectiou of 
Ihe inner table may bnve boen completed. If an q^erture be detected, 
then the instnimenl, when reapplied, is inclhied lo the opposiie side, 
and moved with increased caution and lightness. Want of [►arallehsm 
in the two tables of the skull renders sLicb precautions essential to a 
safe pijrformaQCB of the operation. Section having been completed at 
all |>oinlR, the detached circle is to 1m> removed. Porhnpfl it may 
come away in ihe crawa of Ihe inslmment. If not, dislodgnient is 
effected by the ^Hjint of a lever^ or by forceps ; and the circle is gently 
withdrawn : — in tbia step of the procedure, as wel! as in the last of the 
Hawing, much care beuig token to avoid injury to the dura mater. If 
any rougb or shaqi pointe are foitnd on the margins of the aperture. 



46 



OPEBATION OF TllEFHlNINO. 




Fig, B. 



I 



tleaa are to Ihj removed by the elevator; otherwise, the dura oiutur 
might sustain injury, 

Wheu the operation H iitHlertaken for eUv&tiou of depressed 
hoiie, it is seldoin necessary to remove 
an entire circle. All LhnL ^'e desire 
ia rcjk>ui siillSciuiit for raising the ds- 
prc&fitid pjrtiou, a[id removLii^ frAguieniB 
if need he ; and this can n^ually l>e 
accomplished by fixing the c^nlrc-pin 
on the brink of tlie ;«jiind bone, and 
so removing by the »lw uuly a segment 
of the eiiclu. 

Tho oporalioiij and tho object for 
which it wjLS undi^rtuken, having been 
ocGomplished, the flaps are carefnilj 
replaced, and the geiieral irouad is 
invested by tepid water-dreHsing ; care 
being tnkeu that im iiudue blei^ding 
takes place frvm tho eoulp ; and, in 
regpard to tliift poiat, it in to hv. remem- 
bered that vessels which do out blei^d 
during the state of depreBsion, tnay part with Ihcir contents freely on the 
eBtablislimcnt of reactiuu. Abovo llie water- dressing it is well to place 
a few innis of a bandagt^, lightly ajiplied, so as lo afford support ; 
and thia is more csptcially ncceeaury when doficioiicy of the eruuiiim 
happens to be consiiiernblc, Tlie wound, in otljer respects, is treated 
in the ordinary way; union takinsr place by the si'cond intention. Of 
course, rest L^ abBohite, severity of regimen is estreme, and antiphlo- 
gistics are held in readiness, for some couhiderable time after the 
operalioa. It has been proposed to replace the removed circle of 
bone, jd'ler completion of our object, in the hope of ita becomiog 
reuiiiletl; but sncb hope has been proved vain, as might have been 
eipected. 

When the wcnnd haa healed, the dura mater is found to have 
become incoqKirated with the soft parts exteriorly, and the breach in 
the cranium is not filled up by bone, but by deuse membranon:* fuimu- 
tirtu. A meagre film of n«w bone may be found at the more margin 
of the Aperture. And this^ in ti mo, extends eeiUrii>etally ; apparently 
by the slow secretive action of the parent bone ahme, the pericranium, 
dura mater, and otLer soft parts, seeming to be incapable of ostific 
at'tion- At the margin of the ajH?rtiire tlie new bone may be of simi- 
lar thieknesB with the cranium ; but as it extends, it sljelvea rapidly ; 
becoming very thin as it opprouclioa the centre. Many years are 
required, ere O'iseoua reparation is complete. And in consequence, it 

Tig. 9- TrfpUinio^. n, tLi-souci'l poctUfu i>r^nULiuia i A> ill? dvprvAKd. Tbfl tflnln^ 
pia IkffteDtd on ttie brink of thp nond portioiL 




OI-SKATJOK OF TIEKPUIKIH^J, 



47 



h ecpMlwDt for ft long time to ganxd tie imperfeut part from ex- 
\tna\ injary; a piece of lentbcr or metal beiug worn over the 

At one dm^T tropliining vfa6 fiv^ueiuly performed ; and on grcmnda 
nocb tcHj blij;lit. Frijm tlie (ireceding romurkei tlie following brief 
aledoctiona tnav be Jrairn, a» iu its pr^fiijut nst'. It is bail recours^j to, 
K On ftcconnl of punctured fracture, aa soon ue poBsiMe ; whether 
bewl sytaptoms cziat or not ; tbe object being to remove splintered 
fra^menU of iLe inner table. 2- Oc account of depressed fracture, 
vcoDjpaikied vitb urgent BymptomB of comproBsion ; wlieu elevaiion 
of tfao depreiiscd pirtioii caimul utlieruifiu 1>e eCtoltd. 3. On account 
of duTft-niAtriil ubHi^esSt whf?n lueal anJ constitutional symptotoa miOi- 
dentJy concur in iiointing out the exJHlence and Bite of thin morbid 
condition; tbe gbjtct beiug to effect estern«l eviK-iialton of the pus. 
4- On account of urgent compresflion caused by cxtraviisated blood; 
only when the circumalftnecs ore such as to indicate the »eat of extra- 
Vai&liop, arid wUen that bap|>et]B tu b« Accesaible. 

Ocoo^ondly the surgeon ba« been c:dled upon to trephine, in oaiaa 
of epilepsy, in which the diaease seemed to be conoected — iu tbe rela- 
tion of elTect and caii^e — with a depreBsion of the cra[iiumj the result 
trf former lEJury; or in which circumBluncea seemed to point with 
much [lUinncue to a certain spot of [ho crauiutn — porhapa the Bcat of 
I internal enlargemeut of either a globo:^ or sjjiuulaled character, Tbe 
opifrationf under suoh circumstanceB, ie of doubtful expediency ; but 
may be performed, at the fiuepet^Ied Bpot, io obedience to tJie urgent 
entreaty of tbe patient or ht9 frienib. 

Trephining bait also pruved HueeeBaful on account of neuralg^ia de- 
peodeut on inwatvl growth from tlie cranium,' 

lij general, it is nell to avoid applying the trephjnt in thv direct 
cirLimo of the middle meningeal artor)', or over the longitudinal ainua. 
Yet if it eei^m of deeidrtd importance that the iriBtiunient slitmld be 
applies! at such localities, tbe risk of hemorrhage need not delet ua. 
A eompreBS of lint, directly and accurately applied, will readily rcRtraiii 
th(> veuuUB bleeding; and if & Bimilar application fail to Btaaoh the 
arterial flow, the ofrseous oanal, in whii;h tbe vessel la usHally imlw^dcled, 
may ho temporarily pluggoil^ by tbo insortion of a sm^l portion of 
wood or cork. 

Wounds of the Brain^ 

The bruin may sustain an incised wound, as by a sabre cut; a 
oootuaed ;aid lacLTHted wound, aa by depressed frat'lurej a pmictnre<l 
Wuond, as by the tbruat of n bayoriet, pike, or uny other uharp-poiatcd 
weapon ; or a gunshot wound — uf the tdass " contused aud lacerated/^ 
— by the penetration of n bullet. Tbe liktlihood of disaster ia grave 
and imminent; by extravasation of bluod, in tbe Brut iniitaiice; by 

* BuBE^iEi yiftL ADtl Surg. Jniimol, Aiiguat lB4ti, p 63, 






48 WOUNDS OF THE BRAIN. 

inflaminntion and its results seconilfLrilj. Treatment requires to be 
proportion all J' i\'fltcliful and energetic. 

Incised wounils maj simply penetrate, i>r partially detach a slico of 
the organ. SucIj a flap is not to be at once removeU ; but eboiild be 
replaced, along with the correapoiiding inveeling tcsUiTCfl| iu ihc Iiopo 
that rennion may occur. Exatcplee are not wantiog of a fortnnhte 
roBidt * 

fn contused and lacerated woimds, a certain amount of inflammation 
is inevitable. It is our businefis to moderate and control Ibis, by the 
ordinary means j ho preveotin^ diworgajiizalion and protrasion of the 
cerebrat ti^ue at the injured part. 

In piini'lared wonnds, iaflamination is not inGvitahlt? — nnlees 
foreign matter lod.ijc — yet it is very likely Ui occur. The ttntiphlo- 
gietic precautions require to be very rigid. 

In gnnshot wourds, danger by inflaiumation ia pre-eminently great. 
Not only is the wound of the contused and lacerated kind ; lliero Is 
also grcEit probability of linlgmcnl of llie bullet, ar jmrliona of it, or of 
fragments of bone which have been displaced and driven in. And it 
is well to rememher, that the want of an apparently sufficient aperture 
of entrance is no sure proof of the hall having not penetrated and 
lodged ; for, in the young more capcoiully, Ihe inherent Ldaslicity of the 
osseona tissue may be no great i\^ to diminish the space of cnlranctf- 
wound very coiiBidoTably. Contusion and laceration ^»f the cerebral 
H^RUP, and its inv<?j^lni^nts, render n curiam unionnt of iTjfljimiTintion 
inevilable ; and the lodgment of foreign matter detemiines the amount 
and intensily of this to be great and haziirdous. Further; foreign 
Fubatances, penetrating deeply, are not unlikely to interfere with the 
most impnrtam portions of the organ — at its lower and i>ofiterif»r part — 
producing death, either inslanilv, or at no protracted period, by direct 
iuterferenee with futiL-tion- 

Lt/dgmeni of Porer^n Bodiea. 

When foreign biidies penetrate the brain, and their site of lodg- 
ment CflTi be iLBcertuined llirtiujjh the wound, the nurgeuii naturally 
becomes desiroiis of efT^'Cting removal of so palpiible an exciting eauEo 
of the coming inflammatory process — the rcfsults of which he so much 
tbeads, and njt without good cause. If extraction can be cflecled 
e,isilv, by forceps, probe, or hook, without much additional injury being 
inflicted on the cerebral listuie, it should cerlainly be attempted with 
ah little dflay at possible. If, however, the site of lodgment is un- 
known, or if the foreign bo<ly, of no great siaf, is foimd b'th difficult 
of access and firmly imliedded, it is better to abaUin froui the iuilielinn 
of exploratory an<l evnlKive violence ; which wouhl be certain to kindle 
an amount of inflammation quite uncontrollable. It is TfCtter to with- 

' ^AiiWBT, Clininiic Chimrgitftlej torn, h |>. HO. 




HKRNIA CEREHKI* 



49 



hoM all direct interference; contenting' ourselves with bnsf nntiplilo- 
gistics, t'j meet that amount of the iDflaiomiitjry j)roces3 — ■fM.'rliaj>s iimen- 
abk to cimlrol — which llie infliclitm of llie wound uiid llie lodgniont of 
ft>reig(i miLtttr ciLuni>t fail Ut induce. We lus-y hai'[n]y siictteil ; tliongli 
the g^n^ral prognode is doubdf^^ unfarowable^ Thera aro inBtancen 
on record of bullets, lodged deeply in the brain, remaiuitig there 
harmlesB for years ; incased in ftdvenljliijufl t-ysts— a* hajijiens in other 
testures. Such fortiin^ito patients, hoiTcver, require tvyr !*> be moBt 
careful m avoiding all icorditiate excitement of tbe cercbrnl funcrionR, 
Hud of diL- gencnLl circidalion ; fur it haa liajjpcuedj again mid aj^ain, 
that — fiftor yL':ire of immuiiAty — a debauch or violont emotion hua 
induced a Budden and falal cnma. 

The nUe of prauticu then ifi; That, while it is very deHirable, at 
Bfl early a period as ^lossiblc, to rennjvo fon'igu subBlaDces which have 
lodged in the briiiu, in order that we tnay hope to contend more snc- 
cthafully with tlit comi;ig iijfliiminatiuu — aticli renn>val is n^ft lu b© 
ftttenipted ftt tliG expense of further and seriuiiH injury to the cerebial 
tjfljtoc, Snch additional injury wil] render tiie inflanimatury piocesa 
uncoQtrolluhle ; and the patient intiBt perish thereby. Leave the purt 
undistnrbed, and tnist to general antiph logistics ; for it is p^^Bsible that 
Ite inflammalory process may be kept within Lnodcrale limilst ajid the 
patient tsavtd. Suiuetiuieb tbcy iiiuke wi>uderfi]l e^a^ies, aA In the 
instanee of recovery after an iron bar hud completely traversed a large 
portion of the brain.* 

Hernta Cerebri. 

By this term is meant protrusion of the cerebral substance thron^h 
cranial deficiency. To cuiJiiitiite this morbid siate, three thin^-s usually 

GOnapito; deficient apace in the craDiiim - a curreaponding- aperture in 
the membranes of the brain, by wonnd, ulceration, nr sloii^hing; and 
dj&jrganizntioii of the currcHpondin^ [>ortiun of cerebral mibstante by 
inflammation. It ie most likely to follow on componnd and coni- 
minnted fractures of the skull, with depression of the fragments, and 
laceration *jf b*>th brain and membranes. The pouting prominence of 
brain at fir&t merely fillt^ the cramid onfict \ it then &hoot3 above it ; 
and, in no long time, It may attain to a conniilerable size. Now, prc- 
bablv, iia nech becomes impiic ted in the cranial a(>er!iire, is slranf^i- 
lated there, and slunghs ; a fresh protni&ion, however, tak^-a place, 
and the progress is as before. FL>rtion after portion of the upper part 
of tfce hrttin may l>e lost in this umnn«r, Tvithoui apparent and direet 
injury \a the cerebral fnnclioiiu ;f Lul, soonur or later, the formidable 
constitutional irritation which accompaaieH will prove fatal ; and there 

• Bigelow ; Brit, ud For. Rot., Oct. 1850, p. 643, 
+ It luA been 5nppowd thitlhe loat purtioDb i^f nurplpriJ eiilnlaiiiv am ir^L^aBra^nl liy 
a nrpUTAtive tifTort im tba port of ttii^ brain; luid iJiut (hu^i.hi^ nrin'iinpaLrmvniufctrcbmJ 
fiiimtioii may he Kconoted for. — Lnmtl, Nu. \Vf&^. p. 70O. 




/At-: 





50 UKHMA GBR£1IHI. 

iH Lesidt<4 a risk of ihe diBorgnnizing indiimmatiiin extending widely 
iind fiitally from the original site. 

Prevention may be in oar power. Wben tbe lirain lias Leen 
espoBed by compound, and cumtniiiiited fracluro ; anJ when ihore is a 
deficicDcj of the crjmium, by removal of Uic fi-agmenis, \iiih nr wiih- 
out use of the Ittpliiae — Ibe occurrence of certbrnl prolrufiitm, in con- 
eeqnene<! of iriSummiLtory Arc^c^t-i^inT is alu'nvt^ to hn ajijirc^hended. 

And Iwo indiculions fall (o be ftilfilltd. 1. To atime for the craoiol 
deficiency, by affording imifurmj Kteady, yet gentle Kiijjport to the part, 
by comjireEs and bflndiige ; renewing the dressing as often as cleanli- 
ness aitd propriety of njani^ineitt require. 2. By auiij^tilogiBticB, 
timeoiia and efficient, to prevent or oootrol the othcr^-iae diaorganiEipg 
inflammalion. 

Ad attempt io cifre comprjaea greater difficulty. The obvioue 
indications are, to restrmn the iiiHaininatory jiroccBs; and to repress 
(he exnl>crani growth. The former is to be fulfilled by an li phlogistic 
treat men I ; b'Jl this must be moei wnrily condncltd, inaianucb as by 
Ihift lime Iherc ia no tolerance in tie i^-slein of Eevere remedicB of thai 
charsiclei'- To fulfil the second, tiirte menns msiy Ije considered 
effeclnal ; preBsore, ablation, eticharulics. PrcKsiire is to be preferred ; 
direct, accurate, steady, firm, bnt not severe — otherwise symptoms of 
comt>resaed brain miglit be induced, with» not jjnprx>bflblyi aggravation 
of the inflammatory risk. The bydrusiaiic pre&siire, as recommended 
by Dr. Amot, may be found highly available. Ablation of the cere- 
bral pTOlnision iH not espeiiient^ nnlt-ss; ihi* pnilnidod part be in a 
sloajrhy condition, and mnst nlliinal^-ly be lo&t ; or unlesn pressure, 
alone, have been duly tried, and fonnd ineffectual. In eiihcr cflse, the 
protnidiiig lx>r1iun may be sliaved smoollily off, by a knife, on a level 
with the cranial aperture ; and then restraining pressure is to Ire 
resumed. The nae of eschurotics is, in no cnnc, advimiblc- 

Tho IriTe hemiii cerebri consists of cerebral substance more or loss 
disorganized ; often mixed *vilh gnimons bluod, and other inflamma- 
tory products. Sometimes it contains^ or is based on an nccnmidation 
of pue, of other iniiammatory exudation. Theu, jmncttire of the mass 
may ptThaps be useful, as a meuns towards alleviation, if nut of cnre. 
Its form ft III jn ia always a must unfflvonrftble fiign ; and the ijltimate 
issue is seldom hut unfortunate. The affection if^ sOTnclime^ simnlnled, 
however, by coaguhim. A mass of clotted blood, miied with inflam- 
matorj' exudation, bnt containing little or no cerebml Bubslancf, may 
protrude ; presenting almost Ibe same appearances ^is the genuine 
tumour. This is amenable to more summary treaimout, and liesi>eaks 
a more bopcful issue — fdthough ueiially u sign of aclivc infliimmudon 
baring Bti^eii on tlie part, and calling- for a proporfionnte activity in 
antipblogiBtic?, The projeclion is at once removed, by knife or fingers ; 
anil firm occupying pressure is &i>plied lo the cranial aperture. 



• 

•./:". -■■- :.:•..:: • ■•:.:.'.•. : 



VAEUOEtrrssis capitis. 



51 



ParacejiUsu Copitia. 

The operation of lapping the brain in chronic hydriK^epLalus, 
known to HipjMxnttes, anfl fratliaiMl by the surgeons of the laiddlo 
agea,* enjoys in the present day no g^reat repiite. Of modem practi- 
lionPFH^ Dr. Conijitesi haa shewn the greatest favour to tlie procedure ; 
&ad bifl experience of it baa been Ly far the must fnvonred by euc- 
oesa.-)- Of nineteen cases in whirjh the operation was performed, ten 
were ** living wlicn last heArtl of/' f 

Dr. West has cflllected, from varioue sonrres, fiftj-eix cases ;§ of 
which forty died, Bisteen only it'covering. Of the fatal ciises, six 
died within fonr days; sis within fonrtcen days; three within one 
monlh ; nine within three months ; only one eiirvivod the puncture eix 
tnonth)^ ; and none AiirvivM the Ifiat pnnctnr? more thun lliirty-fire 
days. Death took place either by cxhmistiou or under cerebral symji- 
toms. In many casee, in addition to the presence of mnch fluid, the 
stdjfitance of the Iraifi was fimnd softened ; and, besides, " then: exisleU 
in sixteen of the coses scrioiis orgajiic disease, or maiformation, of tbo 
Wain itself." 

The seronB ocjumoKtioti Tieiially lakes place in the ventricles ; and 
the brain, if not c^ongenitally deficient, [a Aprt^ad oitt and attenuated, 
with its convolntions smoothed away ; the ventricles ultimately consti- 
toling one larj.'e cavity covered by a thin layer of cerebral snbstance, 
wljieh lies imTne*lialely beneath its own membranes. Sometimes, en 
the other hand — tlunigb cumparatively rarely — tbo liquid is immediately 
VL'itbiLi the dura mater; ami the irain^ whiuli in ihebe cnse^ is nmiully 
partially deficient in its commissures, lies at the bottom of the serous 
(/aviry. 

Remedial means in chronic hydrocephalns consist of purgatives, and 
mercurials, assisted by gentle and uniform pressure on the head- 
Failing tbcae, tbc question nJiaea whether the paticut is to bo aban- 
doned to his fate, or an attempt made to ftntc hini by tapping. Som**, 
acting on the printiple **anu*epd remedium miilins quam nullum/' 
oj>erate ; Ihe majority d<_^cline interference. Statistics, in the aggregate, 
H& we have seen, hold out no flattering pn^sj^ct of fcuccea^. At the 
same time, in an otherwise hopeless case, if the parenia, on a fair and 
fiill TepreHen tilt ion of every circumatruice having be^n made to tbem, 
are willing and dL'birons ti> undertake the mk, there seems to lie no 
insujierable reas^>Ti against the operation being then j>erfonned» One 
of three events may occur ; death may ensue speedily \ or matters msy 



• PhilcBoph- Transact, vi»l. xlvli. Ann. 17fil. 
f Mo-LUniI Gutottv, Ikljinli 1S.'V4. 
X la Dt- Omqnc^t't ciucts tJie ^^reulv^t quAJithy iif Hiiiil drawn iiff at one thiiv wsa 
S^i the Loriti^I toljil nuuut^ty 3-'^7i ''t 3'^; (hu gr^jvlusj riiunbcr i>f operations iji any 
(418 cotD, tiw; pprformwd ot Inlcrvi&li uf Tnup Ivn to eui w&clui. 
g MedK^Gu«tt^Ar>rillJ. IU3' 



53 PAHACESTESIB OAPITIB. 

be li^ft much aH thuy vrere, ibe bf Ad refilling ; or a. ?ure niAy be efiect&d. 
Hoping for the last, the eur^on prix-eetl^ thua : — 

A smal! trocar is introdacei iierj^ndicuiariy tlirongb the bre^a, 
or in llie corOTul witni'e, at a Kife distance from the longitudinal sinus 
and iis feeding veins; and it is seldom uecessftiy to (leiieirate further 
than alxfut two iochus. Withdrawing the trocar, tttar acrura flows 
through the canula, and the more gradually it escappB the belter; 
compensating pre!?sura being at tbe same time made on the head, by 
the hands of an assistant, Shaiild the pulee become quick, the pupils 
contract, aud the f^i^e suddenly change its expre&^ion, the fio^v is 
stopped for a time, Faintness occurring, the diild is laul horizoulal, 
and a fe^ drops of ammLinla given in ^ater. Sometimes hlood cnmea 
throAigh the tainila, a. sign that r vein hsu* been punctured;* Bomo- 

times the flow becomes obstructed by a portion of brain, and tbe cauula 
requires to he cleared by a probe. 

After enough has been Jrained away, the wound ia shut by means 
of collodion, and the whole head is tarefully wud miiformly supported 
by elftatic etrappiiig. Shoiild slight eeri^bral cxi^itcinent follow, it ie 
wtll ; for HTiccpfls in mns1 probable in BuHicflSeK; n healthful result 
beinj^ iuducud by the excileineat, as after injection of hydrocele. But 
in general, mild doses of the liytlrar^rum c- cretu are QBeful, as a 
check against escess. And when this does occur, rur main reliance 
will be plaCLsd on mercurial iuflneiice, with topical depletion by leeches. 

In the most favonrablc cases, wc can scarcely expect a successful 
issue but by repetition of tin- tapping ; and lhe amount of interval must 
be reflated by circumstances, in but one case huve I ventured to 
operate. The first tapping proved highly satisfactory; tbe second 
terminated fatally by convulsions. 

■ Wmiaoii"! Lecture*, Medic*! Gazette, March iS4l. 

Id coDFLectinii irltb thb chapter, be^iidcd ihefifouii^t? refBrcrvcei, sen Dean* on Womids 
of tbelltad, l>ub- 1700; yoUon Injuriwof the Hca-l, Lond. I7til>; i'ott'* Horgery, by 
EHrln, LonH. 171)0; rV-fliilt, Oliivren t'liiriirfj^iculps, PnriB, \H12 ; Al*rnc(hy'H Surgery, 
vol. ii. Lond. [S15; Br^xlie, oq Injuries oftlie Brain, Med Cbir. Tram. vnl. xlv. jiart 11. 
p. ilii-ii (Jaiiia, 'Iraiu^ dca I'biies de tetP, Paris, I*J5: A, Cooper, Lixiuri'i on tinrgwy, 
Labd, [8U5; SJiorp, un IrjuriDd of iba HEAd, ISll \ Gnthrw, on iDJuriru of [ho lloul, 
Lond.l8U. 



L 



d8 



CHAPTER IV. 



DISEASES OF THE SCALP AND CRANTUM, 



Eiysipefas ofthf Scalp. 

This difleos^ may bo idiopo-thic ; and tbeti it lu usually of a mild 
character, so far as inteasity of the local affection, ftTid its effect on 
textnre, are concerned. Tt is very apt, Lowever, to supervene on 
wonnde; more especially if mimerons drag-ginfr stitclies have been 
unwisely used to effeci upproximution ; and, siill more especially^ if 
tliese Btitclea have been allowed to vvoik tbeir ow ii vi ay out by inflam- 
mation ftnd ulcerutinn. Suct untowurd accession to ficalp wounds ia 
also mnch fiivoniwl, by ang-cnial conditions of the atmosphere at 
certain sea-soia ; ae well aa by previous derangement of the prima; 
vife, or habits of inlemfierance on the part of ihe patient. !f the 
phlegmonous form occur, dimmer to texture is greal ; by diffiiso infil- 
tration both abtfve a.u'1 beiiL-atb tbt' Ituditious espftnfiion of tbo oci^i- 
pito-frontalifi ; and the constitutional symptoniR a.re proportionally 
urgent. 

The cbief peculiaritiea of erysipeliia of the scslp, in a practical 
point of view, may be conaidered to bej — the unfavourable nature of 
the parts f<ir snitablc treatment of the lailder csaniples, on account of 
the presence of hair ; the unfavourable nature of the piirte, on account 
of the preK(?nct* oF a large amount of tendinous txpaneionj for safe pro- 
gress of the more grave forms of the disease; and the dangeronw pro- 
pinquity of the affected pnrt to an organ of the greatest importance, 
which is ever liable to enffer — either by exteneion of the iaflammatory 
process, or by metastasia, 

TrcatwfnL — When erysipelas Ihrealena to seize npou the scdp, 
either directly or by eiteusion fmra the face, it ia our first duty to 
have clean abrasion of the hair effecled, bo that the necessary meaBureB 
may be fn!ly in onr power when the accession does occur. In the 
case of extension from the fiice, tlie disease is nsnally of the simple 
character and limiied to Ihe skin. And it is well to attempt lo turn 
it from ila upward couraei by placing a guard by means of nitrate of 
^Ivor, while time and space still permit. For cnre^ hot fomentatiomi, 
with or wifhout jiunctures, usually suffice, in addition to the ordinary 
conatifntional management. Cold, or other repellents, must never be 



54 



EltYSirELAS OF THE SCALP. 



I 



employed ] they may be grateful to tlie Rensntions of the piUfnt, nt 
the time; but the risk by metaKlasis is overwhelming. Evpti the 
direct application of rutrafe of silver to the erysipelatiue part is not 
adviBable ; for a BiniiJar reason. Esppcial regard mnst be bad to Ihe 
interior of the hc.ul, bitth during lliu yrogrtaa of tlie disease, and for 
Bomc diiiya after ils apparent dcclitic. For, it has not nnfroquontly 
happened, ibnt conrali?sei?nee h:iB been fliidilenly — and perbapE min- 
ously — internipted^ by inflammatory re-acceBsion, not in the part ori^i- 
tally affected, bnt in tlie raenihranes of the brain. Tbroiighont the 
treatment the heiid iB kept high ; the patient being almoBt in a Bitting 
posture. 

Tbo chalybeate tn^atnient is not contra- indicated ; but must be 
conducted with upecial regar*! to Ibe risk i>f cerebral ilinonler. 

If the pbleg-uiononB ft/rm declare it^U in the sculp, aiid dana;eroiis 
infiltradon have nlrcady begim, we caiino! too s<»on make the renmeito 
inciwons in those parts which plainly demand lliem. At first the 
knife need not piiss Itejond the Mib-iii tegumental adipuse lissnc, fortbe 
diaeaso has, as yet, gone no ilceper ; but if, fmm ncgWt or otherwiso, 
infihrntion lie already suhlendinmis, the knii'e must pierce tendon too j 
otherwise the invariably at^'i^ravuting tenfiion canni>1. bo relieved ; pain 
will increase greatly and the inflammatory fever will rise higher; 
matter will burrow rapidly over the pericranium, and probably bi?ncaUi 
it alstij ami Ibe disease will txlend widely — perhaps invidving the 
cranial eontcnta, in at Icaet a minor form. Timcona incision through 
the tendinous expansion is thu only meaTiK whereby sncb extreme mis- 
ehief may be mitigated ; but it is anroly belter practice, by an earlier 
and leB8 extensive wound, to prevent all such caHualtics ; eflectmg 
recedence of the disease while it is yet limited to its criginal site, the 
ekin and subinlcgrimental tissues. 

When burrowing of matter has takei; place beneath tbo tendinaiu 
expansion, it is not necessary to lay the track open thronghant its 
whole extent; but only, hy the formation of a dependent opening — 
with a suitable co<inter-o(>ening, if need be — to prevent })urnleut %c- 
cnmulatioQ, and to afford the parts an opportimity of effecting reunion 
by grwiulaliim. To iissiai in this indication, uniform eupport by 
bandaging ia very useful, after the acute stage htm passed by. 

When the scalp has been nnderniiried hy pus, even eKtensively, it 
does nnt follow that it must necessarily slough, in any part of the nn* 
dermined portion. Its vascidar supply is ni»t Bo dependent on the 
■Hbjacent areolar tisane as is ihnt of ordinary integument; the course 
of the raniificatiouR of the occipital and lemponii arleriea being rather 
cutanctma than EuV'Utancous ; and the iaulalcd akin — beari^ig its uwn 
vessels — consequently relnining Us liiipply of blood but litlle impnii-cd. 
Aware of ihe dangers of erysipelas of the ftcalp. it i.n plainly our 
duty in the nianagemeul of all wonnds of the heall — however trivial 
they may at first Bcem to be — to avoid everything, in part and eystem. 




TUHOURB OF TUK SCALP, 



illt 



ca\cn\o,ie^ to locliieo an ninJuo anmunt nnfl kind of the inflftmindtory 
process : mnpe esppchilly W, by prsviona inJiH|ifisilloTi, or BiniflttT atnioH- 
pheric inflnence, Lhe puUent eeem to be preiiie[)06ed to ervsipelutons 
occefision, 

Tttmoura 0/ thr *^aljt. 

Enc7/$ttd tumours^ coiDUionly called Wons, arc found more fre- 
i^nently on the bciilp (ban in any otber eitnatioii ; unrl t}\&y am Ecldom 
Htngle, In general iLey are reg-nrded mainly as deformiliea ; but nheii 
they inflame and opon, lbi?y may beciime both troubJesonic nnd dan- 
*;rer<ms. In sonicj cases dangpr has arij*en from the pro^tas of mere 
growth ; the calvarium having become abfioriMsl, and roiiBcqnently defi- 
cient, by ibe inwnnl prt'SHure of the Uiinour. The unly ailvis^ible 
mode of treatment ia removal by the knife. The maui danger lr» h© 
encountered w inflammation, asfinuiiny the erysi|>eiaton» dinracler; 
abd thifl mu^t accordingly be provided against by tiuitablc ci^MBli- 
tutional treatment, as well befi>re as after the ojieratiow, and by gentle 
ahd earernl miinagenienl of Ibc woniid. 

If the Innumr be of large Ni>^e, it is removed by re^lar disseqlion. 
By two elliptical inciHiuDaj uf mcrdy subcutaneous depth, the redun- 
dant intagnment 18 detflchfid ; and then the cyst, carefully preserved 
entire and tense, ia leisurely dissected from its connexions, and taken 
away along with tho portion of Kocrifioed integument. The flapw of 
saved skin are then replaced ; and, on oozing of blood having ceased, 
they are brciitgbl into accnrate contact ; the wound being treated wllh 
the hope of adhesion- Approsimation is eSecte<l by strips of iainglaBs 
plartter ; or by collodion and lin( ; and to facilitate the application of 
these retentive raeans, the Burronndifig scalp has Ijeen pi-eviouely 
shaved. If oozing of blood have not wholly ceased, it is advisable t<i 
maintain accurate pressure on tlio whole wound fi>r an hour or two, so 
HA to prevent taward accumulolirjn of coagulum, an event neceflfianly 
fatal to adhesion- Indi.'ed, ench pressure is advii<able after evory EUch 
opernlioD. Stitches are neither necessary nor advi&dde. 

If the tumour be no larger than a nut, or small egg, it is rinne- 
CBsaary to remove any integumenl ; jjnd rcgul.ir dissection Is therefore 
not required. A more summary process sufiices; that by incision, 
eitnislun of the cuntL-nts, and evulsion of tho cyst. 

If an encysted tumoar, in a pAlieiit advanced ia years, Have ia- 
flanied and suppurateil, and be in process of intractable ulceration, it 
is well to destroy the part effectually, either l»y esohnrotics or by exci- 
sion — the latter mcthvHl the preferable; for malignancy of action in 
otherwise apt to be assumed. 

Sfiiid titmniir^ tit varions icinda, are occasionally foimd in thin 
locality. Of thene, the luo^t common is the adipose; seldom of large 
size ; and amenable lo ibe ordinary treatmeot — escision- Uf whal- 
cTer nature the tunionr be, ite removal ahould be early ; ere incorpo- 




56 



TUMOURS OF THE SCALP. 



rition has laken place, either with the ecalp above, or witli the fibrous 
lextnres bcnofilli. 

Erectile tumonra very frequently occur in the scalp, Thej are 
beat treated hy dcligation ; with or witb-out prtvious reileclioD of the 
integuiceot, oecordiii^: ob this bo-ppona to bo involved or not in the 
morhiJ strneliire. 'Die very large tnraonrs of thit clasE, BometimeB 
met with on Ihe g\*\q of the bead, need not be tied all at once, bnt 
ciay be dealt with in portiona; different parls tein^ elrangiilated at 
dlfl'ereni perio<b, Esperienee has proved that, in suoh cases, attempted 
eicdsion ia frHiigbl with (be uLUJOSt daugcr to life, and that ddigalion 
of the main Arterial truuk, or tmnki^ 13 an insafEicient ri'inodial 
means; CHFes miiy ocenr, however^ in wbicb, a» part of Uie cnre, the 
prinpipal Jirleries may be i;bliler,^(ed as they enter the tiimonr; the 
t»isl:ed Bulnre beiii^ eniployefl for lliia puiimse, aa in the case of 
voins.'^ 

Miilignetnt tuvioura occaBionally fonn in ihe a(:al[) ; fullowing the 
nuual course ; and amenably to iho ordinary treat- 
ment. "Benefit is to be espectpil only by free 
excision ; and that can bo practised with ex- 
pediency only at an early i>eriod. Medullary 
liniiaurH may ciiinmeiice in the soft tisRiic^ and 
involve llie Iwird secondarily; fully aa ofleiiT they 
ori^iniito In the bono, 

MaUgnaut utrnr < .f the TJealp in not nncommon ; 
bcfiinnin^ as a warty excrescence; or tlie result 
eitLor (jf an un^inally simple sore, or of an open 
and degenerate enc3"sleJ luiuuim Early jmd free removal is had 
reeourae (0 ; if Ihe lym|tbatics as yel present no conlra-iiidicalioiL 




Pericranitis. 

The pericranium becoTnes tie seat of an inlliimiiiatory pTocesB, 
with or wiLhout external injury having been applied, Acule, it may 
be the result of wonnd or bruise; followbig the ordiLiar^- auirse 
of such diacftse in tibrona lifHius. Or ncule ftiip]»nvutiim nmy estend 
from ihcEiirf^ce; as in erjsipeln-S of tlie jililc^^nnonouR form. The 
uanal antiphlogistic indicatiotis require lo be fidlillcd. 

Idiopathic p<j no ran ills is more frequently chioniL' liian acute ; and 
seldom ()ccura bnl iu the sduU, who is saturated with the rheumatic 
diathesJB, or who bjis Hustained injury of ihe Kysteni by mercnry and 
BTphiJis — one or other, or hntli. Tho onlinary symptoraa are present; 
pain, Rwtlling, hcsil, tiglitnfsfl ; and the noeturnal exacerbations are 
peculiarly marked. The affcrlioa may resolve, leaviuu liiile or no 



• Dr. Warren, American J'-nrnBl of Medinil SHence, April IMO. 



PEHICltAMITlS. 



57 



atrncltiral t^hange ; or the resolnlion ia iiioomplete, ftn etilargomenl of 
bone rcmjLiuin^ — resemliling a dill'used node. Or true inflttmiuaLion 
is establiuheij ; and the bone sufTerSf to a greater or less oxtent, by 
Tilceration, caries, or necrosis- Usually Uie jicriosleum of otber parts 
of tbe nkelcton is at Uic Bnnie time and simiUrly affected ; and the 
buncB most Uktly to siiffirr along wttk the craaiuiD, are the daviclee, 
stemiiuk, LibiEe, and nliis. 

Treatment is midoly coiiatilutioaab The priiQ*e viie baving- been 
brought iuto a tolerably Bfttisfactory condition, a suatamed exhibition 
of the alteratives well known to be suitable to such caaee ie proceeded 
with — sflrsaparilla and iodide of polftssinm, either together or alter- 
nately. The latter, ej^pecially, is found myst btuefiuiab Locally, 
leechtiB and foiuoiitatione are applied, at first ; tb^n, counler-irritdtion. 
The inflammatory process having been removed, and its reaults only 
remaining^ notldng is more effectiml Ibati the eiidermic use of a strong 
Bolutifjn of iwime. Throughout the wbole period of cure, the hair is 
ke[»t either shaved or short. Atmospheric exposure ia carefully 
avoided ; aud rc^imco ie rigidly non'Slimulant, If niiilter form acutely, 
it ranfit bo ovacnateJ^ freely nnd early. If Lhe abeeens be chronic, 
opening is delayed, and discusfcion by i^nliut atlempted. Even when 
rough add spongy bouu can l>e plainly fdt Ikrough tho chronic collec- 
tion of piifl, ioiUne should still be i>er&evered with — along with th« in- 
terna! Ui* of iodide of potassiiuu — when the affeelion is do|iendent on 
a eonstitutional cause; for, in Eueh c&ise^ dlbcuu^iou ja not iiidikely lo 
follow patient perseverance, even uuder ofreiimfltoDees by no njeana 
prurai&ing". KLuhM aciiLe or subacute aect'ssion supervene, however, 
the abscess becoming tense and t^rescent, let incision be no longer de- 
lay eil. 

In obatjnalo examples of pericranitis, causing mere change of 
Btruclurc, with blight swellhig but great pahi, Ihe j^eatral health is apt 
to giv-e way gready, fporn want of sleep, and consequent exhaustioa. 
In such cases it is essential to give opiates; and if the uiorc pnjijer 
alteratives have proved ineffectual, mercury mjiy be given in guarded 
doses. 

AJectiotis of the Cranium. 

Abacss arid tiicer oi iho t:T^i\am occur ^rom ordinary caueos ^ and 
are amenable to ordinnrj treatmeuL 

CflriM of the skull is preceded anrl accompanied by interstitial 
absorption ; and seldom occurs but with a vice of syatem — seeming to 
be rather a symplora and si^ of this, than to constitute a disease in 
itself. Aiid the predidjioshig vicea of H^stetii are — scrofula in tlie 
young, and Ryphilis, mercurio-HyphiliB, or tho ill effects of moreiiry alone, 
in ihe adult. Treatment, accordingly, is chiefly connlilntional. Locally, 
the diseased fltnicture ia ex[>ofied; and removal of the carious siuface 
IB effected by the gouge, or by escharoties — chloride of zinc, or red 




58 



AFFECTI0M8 07 THB CRAMUM. 



oside of mercury. Sometimes Nature is provident in tliia rtiAtler; 
and herself effecLa the iiccessjiry cleanmce; the iiselefls parts c<>mirig 
flwaj spontaneonfilv, as siiiflll tietiiiestra* If tbe wliole thiekiiess "f Ihe 
cruninm be Jnvolvt J^ tbeie is of course julililinnol Uangcr, by Jura-iuutrRl 
involvement ; and pi'^tflxilion rt'qiiirps lo he exen?isefl aoeonlingly. 
SomctiiiiCH, nnfortimalely, a tnumviraie of scrofn!;i» sypbilis, Hod mer- 
curiaUsra rtigna in llie iijsleni of Uie niiserablo jiatient; nn<i then, an 











:^ii'.v* 



r- ' • \ 

» ■■■-■'v^":-:V^:>-:^);' ^ 



" ■ ■ ' ■„ ■■?> ■ ' 





,-:-s.' 






itb-ii- 



>T»-ia 



cuu rtmlily be undcrbtcod, ibe local ttfTtiudou [iruvea jiarticiiWljr lu- 
tracliiblc. 

AWrosh mTLf involve tbe whole ibickness of tbe Rknll ; t!ie result 
of wmind or not— 11 sTi ally the former* Then, as alreiuiy stiilt^d^ there 
18 ri&k to life by ]iurulent acciionddtion lelween the Lioiie arid dura 
mater ; and^ if no exltroal aperture itlreai.ly exist — us by fracture — the 
use ijf the trephine in dennindtd, 

Ej-fviliatiun, or death of ibe extcmal portinn, is juoro freijncnt than 
compltt*.' neerofiifl; the repnit either of extenud injnry^ op of chronic 
idiopathic pericrauilis. Tbe iiBual course of Biipei'iicial necro&is is fid- 

Plf, 11, Tnt«nti(jBl abfioriiCion in progTHq, In tli« craniimi^ at a, jiiav hqpin; ■! ht 
mow iilvpncFd. Li Tnny fit'ip li^re -. prrnlnfin^' a ineroly I'jinri'lIoiiA stmt of ilio li^ue ; or 
it niny advun<:i-, bLt^'.^Diin;:; merited in uli^ratLfm, and prixluciug rarii?», u iu Fig- ]3. 

surrojndtil bv imerslilifll (iLjMTpiion ; at d^ cntic*. wJUi perroiis, in lli<! icTUrf- — inlcrrtJ- 
tjfll dlBorption «ti]1 oocompanyini^. 



AFFBCTI0S3 OF THE CIIAKIUM- 



59 



Towed, here as elsewliore. Or<liiiftrily, we await |iaiienfly K]tnntAn^nii« 
•wparalion, and tliOD remove the sequestrum- Soiut'limes, when fletnch- 
nient is tedious, acceleration may l>e effected by tbe apiilication of 
escharoticfL Ami fiora^imes it is necpflsary to interfpfe and forcibly 
elevjite thedea"! ^lortion, whicli, though Beparatedrroniihebariiteslures, 
IH ytt cijiifined b_v afjft j^nmiUting etruclurcs fironnd. 

In no form U necrosis nf the cranium ^Ws tbe ordinary formation 
of cortical and aubytitiite boTn- oocnr And bow fortnnale sucb an 
arrari^^ment ifi, at once becomes apparent, wben we consider what 
woulil be the inevitable cons^qiipnce of new bone bnlgrnfT inwards on 
the ibira maler. If the scqueslmm have twen anj>erfieia!, healing is 
effected by a depressed cicJitrix, nA aAer fliujple ulcer of h^rne. When 




ng. 13- ! ■ 1 1 

the whole tbicknera Iiaa perished^ atonement is made for the defi- 
ciency, as after the operation of trephining;. 

As in the case of carleSt many examples of exfoliation of the oraninm 
are dependent en the raercnrio-Bypbilitic vice of sj-stera ; and require 
const i tut ioual Irt'aimt'nt accordingly. 

In connex-ion witb llie trjtiimatic form, it la well to remember that 
detachment of the periusteom — even nidt'ly and witb sorae bniisin^ of 
the lx>ne itself — does nat render ibe occurrence of exfoliation inevitable. 
Tbc part may, and frequently doen, reaiver- And the treatment, in 
the first instance, is to be conducted with a view to such a reeiilt; the 

Fl^. 13. Mvrcurkh' Syphilitic Cohea of tb& skull, a, A portion detadied, in tlie lonn 
•yf fti'^iiefttrum. 

Fig. 14. U'IcQT vf crvnitim hookd. Tko nurgina U.-Tell«l otT, aail i+lnpinif ilovriL. 
The satiate atudded with iiii^ri-Tfect grunuUtiutL ¥tom the Mine cranium MFfga. I J, 19. 





m 



AFFECTIONS OF THE CRANIUH. 




fijf. Jt 



flap of intepTiiment being carefully replaced, the wound approximated, 
and Bpoedy heiilinrf soiiglit for. 

Exostosis of ihv cranium is not uncommou ; r>f a dense, ivory 

character J Jind usuully of 
small sine. Foiiiinalely the 
i^ite of ^luwtb \fi iisiiallyon 
the external afpect of the 
l>onc- Uo Ireatmeul is re- 
quired. Thfl ttfreclion is a 
mere Ucfonnity ; and not 
c?v*n that, nnleaa apparent 
from want of covering by 
hair. 
Spi delated exostosis some- 
times grows from the interior of the calvariiim ; irdiicing iatense 
neuralgia, or epilepsy. Aa already slated, there are aniue few casea 
so plainly cuarked as to admit of the offending hody buing removed by 
the I re phi Tie. 

Tttmotira of the calvarinra — oateosarcoina and oBtcoccphalotaa — 
are rare ; more eBpeL-ially the truo osteiistticoma. When lliey do Ibrm, 
no treatment save mere palliiuion is advisable. The site and con- 
nexions uf the affected parL fi'rbid operative inJcifcrence. 

Polf/piJs of the frontftt n'miis is a rare aftVction ^ and, in iIh firat 
stages, of diflicult diagno.sis. ^Vhen dett'cleil, cure may be obtained 
by removing the bone to puiih an extent os will permit evulsion of the 
grovrth, with subseipient Lautt-rizatJon of its site.* 

Tumours of the dura mater involve thecraninm seeondanly. They 
are soft, fungating, and TiHiiidly uiediiliary. The originid pyniptoma 
are necefis.irily obscure; lot, nfler a lime, the bone having yielded 
lu absorption, the tumour manifests itself externally, and follows the 
ordinary cvurse. Treatment is hut palliative- -|- 

• Bril. nmi V.-r, Med. Hcv.j Jaa. Ifllfl, p- IflC 
t Boyer, (Euvrce C'liirrTr^;- Icm. Iv. Velpcfla, Diet, de llMlecine^ tun. x. 




61 



CHAPTER V. 

AFFECTIONS OF THE OHBIT, AND ITS CONTENTe. 

I- AFFCCTrONS OF THE OfilHr. 

Orbital Infiamiaation 

Is uaually ibe resuU of injury, when [jriraary, SomeLimca it is of a 
BCCocdary tlmtacter, iind unuotmoetcJ wiib viulenco doQo to tbc part j 
an ertenmon of irfl;imniaticm from a neiglibnuring part from the eye- 
bflllT or from the Ecalp. Most frequently it fellows injury. And the 
affectior h usually intena? ; Hi]|ijmnilion being certainly and soon 
attained. Fain is great and incn-aKing; tenfiion is prut, for ewelliag 
ifl hindered l>y the iinyieldiiig pmct-ss of the periu&leal liuiiig uf die 
orbit — lermed ortiit&l Ugftment — which confines the orbital contents 
in front; vision is mow or less imijair^d hy t-orn press ion of the eye- 
ball, and tills i>rsan, nccorJinp to the simonnt of deep Bwcllingj is more 
or less protru'led ; the eyelids are red itnd oKkniatous; iiiflnmniatoiy 
fever is uiLense, and the cerebral fLinctioTis are often prominently dis- 
ordered. 

Treatment compriHeB the ordinary anlJpblogiirtic indicfttiona. When 
a wound eiialB, careful cilLini nation ie expedient, to ascertain whether 
or not any forei^ suletance — as 6traw, wood, iron — Ims penetrated 
and lodtred; and if such an obviL>us exciting t:atu*e of inflimmation be 
detected, it is Ibrtbwilh removed. Leeches are applied in nnmbers ; 
ia Bonie cases, yenenil blixid-Udting may alao be fuund advisable; and 
the antiphlogistic aecoHHarien to blynd-lottin^ — aconite or ftntimooyj 
purgatives, (luietude, &e., will not lie ueglectcfl ; vomiting bemg 
avoided, fur obvious reasons. The part is dili^^eutly fomented ; and 
80 soon as indications exist — however faint — of matter having formed, 
an evacuating incision is practised ; it being obviously of the greatest 
impurlauee to penetrate the orbital ligament at an early period of ihe 
euppuriitiLiQ. On evacuation of niatUr, iho Ejinptoins are speedily 
mitigated ; the lunBion, tbTubiiin^^, and intense pain almuKt immediately. 
If incision be delajcfl, spmtaneous evacuation takes place ; but not 
till after mticli suffering, considerable destruction of texture, and 
flangeroue impairment of fiuiction in the eyeball. 





i'y2 WOUNDS OF TQ£ OKDIT. 



Wounds ofihe Orbit 

Th*se are uwially of the iMinctured kind. As jnst staled, they are 
liable to provi; the exciting canse of int*nise infiammation, more espe- 
cially when tliere (a lodgment of foreign mailer. And the probability 
of Ihe Ifttler circuinstanctj must alwaju be regitrdcd in praclice. Tht* 
^vonl1c) having Wen atccrtam^d. to bo cle&u and free, is carefully 
approiimalfd ; and trilH is continaously apjihed, with mach care, in 
order to avert in Ham mat ion, if possilile, and jwcure union hy a/lhesion, 
If iiiflaaimatiun aiipcrveue, antij>lih>giatic treiiluieiil must be earlj and 
active ; a fiiippur^iting \round is theu inevUabk' ; but we ho|ie to avert 
dii^ep »nd t'lFiifincd abMcH^, uliicU m prone to form by vxteusii>D of 
the- inilamiiialion boyond the wound's track. 

But Kocb injuries acquire a slill hig^her importance, in reference to 
the parietes of ihe oibit. A penclnilin^'' wonnd of the orbit — as by a 
bayonet, pike, or pitchfork— is tn\t onlikelv to produce fracture of the 
orbilal jdaic; and llie fragnienlt^ of the br.'ken bone, driven inwards, 
are ceruin to peuetnle or othiTwi^c injuri; ihe britin or Ixa junubi^neB; 
eDdang:ering hfe, perhapB inimeJijilely, hv tslraviisfltion of blood — 

more probably by ihe results of iriilamoialion at a nioro remote period. 
Sncl wounds, therefore, reqnire to be treiUed with the greatest caution. 
The extent of injnry done to the boue is ascertained as soon, ixa accu- 
rately, and vet ae gently as i>ohsible. if lyuse fragments are fonnd to 
exist, tlietie it hi A^ell to remove ; the eiti^mal noui^d Win^ dilaled, if 
need be, fiir this purpoBe- And when Ihe epicida are ctrtwnly diB- 
plactd inuarrtu, Injiiring the iminiHunt piirts in thai direction, an 
attempt ehoidd he made to take them away ; whether ihey seem 
detached or firm. The indicalion is as paramnuni, as in punctured 
fracture of any other part of Ihe cranium. This importint part of 
the IrL'atmenL hAving beto BaJlbfatitorily accoiaphshed — by dilata- 
tion uf the dstciTtul W'tuml, and the Eiiitablt' hec of fingers, forceps, 
and |>rohe — thp pniient is placed on Ids ficen wilh ihe wimud nnapproii- 
mated, until hlet<liiig ceai»e; internal extraviisatiun bein^ thus ren- 
dered lees hkely to (.Jccur. Then the pirla are brought logolLer; and 
antiphlogiatics are diligently employed, both h>caUy and generally, in 
oMer to avert, if po^isible, au niUoALod umouuL and esttent of tlie 
iiiflajnmalory proccetj. 

Tumours nfthc Orbit. 

Hard Tumours of the orbital parieleB ore uDcociniou. The den»i' 
ivory e^LOHtosin pro<lucet little lUcouveuientT, is asnally of ineonBidcr- 
iible sJKO, aad rcqiiiri'fl no Ijcntinont* Tho cancclliited exoatripia — i>f a 
|)edunculatH cbnracter, and larger diuien»ionti — may iiu-oninjode ihw 
eyeball. If so, the nature of Ibe eaee beJnp; plain — an incirtion may 
be made on the ori^ of the growth; iis neck may be cut by the 



TCHOuna OF thk oebit- 



63 



boiio-pljcre ; and, by c^arefiil diEscctioDf tLe ofTendin^ enbatarico may 
then Ite rtmoveiJ. 

Soft Tumours are of more frequeot occnrrence. And tliey may be 
prturti cully diWJedinIo tliree chifiGeB. 1, Tlic Himple iLnd HnroomiLtotiE ; 
amenable to excnsion. 2, The erectile; capable of cure, but not by 
Jireol <ijjerjition. 3. Tlio umliguaot; iisuaUy forbidding o^icraliuH, 
and ^dmiuing only of pjilliation- 

1- The simple tnmoiirfi — dimply sarconiiitons, fibrnns, fatty, uysfic* — 
may form in the orbital areolar liwjue, unconneclcd with either tbe 
bone or lis iierioj^teum ; and the growtii may be either of idiopatliic 
origin, or a reiante canacipience of sb^^jbt injury. Enlurgcmtnt is slow, 
j^radiial, tM>EupjLralively [minlLisHi niiJ un;itluLidud willi Jnliuiumatory 
Eigns; H'^t liki)ly tbtTrcfLiri^ to l>c mititakuii for orbital iib^cfH!], As in 
the IjitliT iift'eclbin, liowever, outward growth is prevt-ntTid by ihe 
orbital lij^ament ; compression of the eyeball f^>l]owH; and this organ 
may be more or lesa protrnded from its socket. At fii'st, sight is not 
lost, and Hcarctly even impaired ; for stret^binjr of llie optic Jierve h 
graduil, anJ uirvinie as well ad crrebral tissue baa a very considerable 
power of occouiiurxlutkog ittielf to di[>p1aoing itgcncieG gradually applietb 
Ultimately, however, the Btrelching and diBplaoement aje attended 
with more or less kopairmefit of vision. 

By careful impiiry iuto the hiatory of tbe case, we satisfy ourselves 
that the tumi^iir h of the simple kind. Of what esact species it may 
be, it \s not easy lo determine ; fur tbe tense orbital ligament Btretched 
over the ewelling ob&curcs lactilu examination. Generally, however, 
we are jible to satisfy onrselvea on nnother point ; wliether or not the 
tumour is movable — -connected or not with the bone and periosteum — 
conserjutntly removable or not, etilire, by operation. Whea convinced 
that the tumour is simple and movable, we do nut hesitate to attempt 
its o:(tiriiaiiuni A wjiiiid ia made ofHufiiciuut eslcut, in a line parallel 
to the £brcs of the orbiouln-rie mUEvte^ By oaLiiiouH ditiaection, the 
timionr is reached and exposwl. It is then laid hold of by a voleella, 
or hotiked foree|)H; and evulsion oulwardK being steadily yef gently 
maintained, extirpation is rendered both ea'^y and safe. The ^xiint of 
the knife i^ moved very warily, when i*ear or in contact with the 
orbital parietea ; for thcjje, by ihe presKUre of the tumour, may have 
been mueh atteunati^^d ; and a carolc^^ movement of the instrument 
might cause iienetration. The e>'el>a3i and optie nerve are also care- 
folly avoided. After Removal of the tumour^ the former is carefully 
readjusted in iLs projicr phiue ; aud re^^toration of its funclions uinmlly 
ensues. The wound is broug-bt together, and treated fur adhesion. 

Partial removal even of the bimplett luiuoun iu Lhia mtmUioii, is 
obviomily ioeipcdietit. For, rupn^d notion will almowt certainly occnr 
from the ptjrticn whieh remains; and such seeonii foraiatiooK are very 
apt lo prove of an uulavonrable kind. 

3. The Erectile tumour is oci^aMonally found occupying the orbit 





Gi 



INJURIKS OF THE KYELIDS. 



It IS seldom congfinitfll; hut ornirs Rnildfinly, in aftpr life j and i(H 
origin is usually attended with a cunsidenible amount of pain. At 
first aa obscure deep Bwelling is found, cauaiug more or less iucon- 
vtnience ; but as it enlfLrgen, and Ap[>rodclies tiie surfnee, tlie ordinary 
cliantoleristits of ertctJb Usbne becuniti surtltltiilly rtp|tarent. Oflen 
the chefik is covorod "with large veins — recipients of llio blood &om 
the more nclive vessels witKin. 

This tumour cannot be treated rlireclly ; ueitLer knife nor ligature 
are adsHsalle. Tet^ if no renicdial means be adoptedj tlie probable 
issue will be unfortunate; by enlargement, ulceration, hemorrhage; 
by involvement of tbe yrbilal parielea, anil subsequent pretenre on the 
bmin ; or by mere coDBtitution^d irrilation. Experience hns ahcwn 
that deligntion of the convRponding carolld ifi i'apnble of effecting a 
cmiq; not by obtaining consolidation and obliteration of the diUted 
vessels ; but, probably, by diininisbiiig their supply iif blood, removiag 
the impnlse of the heart's action, and bo fflvonring resumption of the 
normal cnlibre* And free blood-lclliug, after the operalioii, would 
seem to contrihutp mntoiially lowiinlfj thjp robult. 

3- TunioiiTs of a malij-'unnt liind — mcdullnry — nre no unfrequent 
occupants of the orbitid cavity. Generally they oiiinnate in the eye- 
bull ; but occasiifnally this ia involved only secondarily — the origin 
being in the orbital areolar ti&sne^ ia the peril )stcu in, or in the hone. 
The sole bupe of eure is by estirpalion of llm whole orbiial t'ontents. 
And tliia is expedient only wlicn the diaeaso is recent, apparently 
limited to the soft |inrtBT and cixpablo of entire retnnval. 



II, ArrtCTiowa of the EvEioua. 

Injtiries. 

Ecch/iitosts iJi of fypqueni octnnence in the eyelids; the areolar 
tiflsuc being las and delicate. Ordinarily it is the result of a bruise or 
blow ; but it may follo'iv a wound, inore especially if oblique or subin- 
tegumeiilal ; ihe appUcftiion of leeches is almnst certa,in to pruduce it, 
to A jL^icater or less estcut. It is important aa a dufomiity. A p/ilieot, 
having rt'ceivHd an iTijnry likely to In? followed by ecfhymosie, ig 
ansious that tliis should be pniventcd ; and, the escape of blood hjiving 
occurred, he ia tipially nnxioiis that tlie diseoloration should be 
removed. Many remedies are jiopularly in vogue for iKith of these 
ends. For the former, the eoiitimious applieatiun of cidd by wetted 
lint, with qnielndt? and abtiLrm;lioo uf all htimuli, is boUi suitable and 
GftBiIy ahtninod : if begun inimtdial<^ly on reei-ipl of the inpiryj and 
properly mjuntained, the natural hemostatics will be much favmired, 
and very probably little or no blood will escape from the torn vessels, 
EcchymosJR having ncci;rred, ihe nature of the applicalinn must vary 
according to the preaeaee or not of inflammation in the part; in the 



FOBEIGN UODIES IN THE EYELIDS. 



65 



one paKe, Fomenbitiou is ^^mploj-ed^ subjugaiion of the mi)H>i<l vaaculrtr 
process bting' tbe paramount indication ; il iIiu other, il soliirion of tim 
muriftteof ammoai^L, or other sorbefacient, is applied, in order Lo basteti 
removal of the eilravasated hlooii hy iibsorpliiin. 

WoHJida ol' tbe eyelids, if contTised^ are treated by the water-dreaS' 
ing. If iutifted, nppruxiiuation la effected by Gdo biiturpa j other 
relcmivL' iikoans being plainly inapphcable to this loi^olity. Grunt care 
nhoiild be taken to restore the normal relative poHition with accnracj, 
le&t deformity enfiuc. 

In the case of burns, much precaution is required during^ the pro- 
cefifl of healing ; lest by conlractiou ectropion mipt-rvene. And the 
oarefu] dreshlii;^ and baiidi^^lji^ iiecetisary lor thiA purpoKc 18 continued 
eren for BOiae lime s-Her tbe farU have henleil. 



Fvrcipi Bitdiea. 

Foreig'n bodies of sniall eiae — as particles of eand, dust, glass, coal 
— very freciuently lodge in the eyelids, on their conjunoiival lining. 
The patient, Buffering laucb jiain and irritatinn^ — -with the eye alreiuly 
rodi intolerant of light, and profustly Inchryoialing — applies for onr 
aid on account of " something in his eje," Gently npeninff the eye- 
lids, before a steady light, we scrutinii^ the eyeball in the first place ; 
diret^ting the patient to roll the organ in varinne directions, in order Id 
fncilitule such examination. If parnidi?R itre foniid adherent, they are 
in ^tneral easily removed ; bj a ctiretle, or flat end i>f a probe 5 by a 
hnir pencil j or by a fold of a soft bundkerchioF. If fine dost orlj- 
have lodged, fomenliktion and uhlulion will ordiTiaiily suffice ; ajAwstinnf 
the laehryrnation in its spnntunpoua cleansing cfi'ort. ftoniPlimeB it 
may be neceaeary to inject a gentle stream of tepid water, by Dieane of 
B small syringe. In other cjises, it is enotigh to shut the eye, or keep 
it shut, for a. few minuicfi — occasionally blo^ving the nose ; thoH 
favouritif^ the ojitiiral wAwliing away of the foreign piircielee, by 
iiicreasod lachrymal anJ conjunctival Keoretion. The eyeball having 
been dnly scaancd^ the lower eyelid \a next examined ; its coninnclival 
lining l»eing readily exposed \*i a sufficient extent^ by shnple depression 
o[ the ^?art- But the upper eyelid is the Hte most frequently occupi&l 
by tlie foreign Huhst&ni;e ; anil it cnnnol ba fiufBrit'ntly exposed, with- 
out evorsiijn. This is rffocled by plaeing a pcvibo horiaonlally aenij^ft 
the lid, above iU eartilat^e ; taking hold of the eyehishes with the 
finger and thumb ; and bending the eyelid backwards over the pnjbe. 
If the fon^ign miilter be b>fjse, it is i-emoved by any of the means 
already mentioned. If it be lirmly bxlged, the point of a tooth-pick, 
or of a couchiug iieedle, w ill uioKt conveniently effect its disloilgment. 

In certain oceupationB, particles of steel ot iron are apr to g;nl 
between the eyelid**, and often become impfteled in the cnraea. Whet. 
loose, Ibey may sometimes be brought to the surface and removed, by 





66 



DI-EPIIABITIS. 



nn*anH of a. magnet of strcng power; but genorallj the point of a 
tMjiicliing ticodle is required \o effect their delnelimeut. 

When DO neiiii^ULnce Is ut liauc], the patient may ItiuiBelf, in many 
cn*ea, get rid of tbe irritating malter; liy elevating ttie upper eyelid 
witL llid fingers uf oi^e tiiind, aud pulliiig it dowawards, while lie at 
the sii[uo time closus the luwt-r, and piieLea itupwftrjJs. Ilnving pressed 
gently ovpr tlio glolw^T '^'' linger Is tlien wilUdniwn, and tlie liJs allowed 
to eepartiie. The cytdajiluis of tlic loner lid aro lUtis miide to sweep 
Che cojijuiiclivai lioitif^ of itie upper; and it i& in thi? latter Bituatioij, 
as already Htitted, llmt foreign bodies of fimall size usually lodge. 

The fordgu hidy htiving been remi^ved, the eyt is closed ; light 
is excluded ; and anliphloginticH nee ouipbiycd a<:cui'ding to circum- 
dtniii^ea. ri in plain tliat if llie foreign siibstimoe lie not romuved, 
inflammflLinn will eerlainly be eatablisr^hed, and probably prove unto- 
Wiird and intniL-table. CasGS are nut wanliog in wbioli complete 
destniL-tion of vision baa been the ultimate result of but a stnull panicle 
of foreign matter lodging in the eonjujieiival lining of an eyelid; 
porbapfl with JUHcb injury dono to the system by severe and Bnatained 
treatment dJrecled ngainat the inflEimmniion and its rcBultB.* 




The inflamrafttory proceas, attacking the eyelids, is bo nameJ, It 
Dfiay folluw injury ; obaumio^ tho ordinary choroctor and cootbc, and 
amenable to the ordinary trt^alment. 

In er\"sipehi8 of the face, affection of the eyelids is uaually a most 
prouiinenl syuiplotii ; the laxity of tlieir areolar tissue admitting of 
much and unseL^mly awellinpr- Pimclurts jlvo usually necessary ; noE 
BO mneh (a abMrai-t blood, ah to evucmxte heruns effusion. After rtecH- 
BiOQ Iff the pi-iuiary syoiptouie^ this port niuat be closely watched; for, 
during convalescence, reftccesBlon of the iiiflammatory attach ia very 
apt to occur, a*lvancin^ rapidly to suppuration. And unleps nn early 
iucinion be luado here, the aliacess will be large, and llio integument 
will probably slough. 

Opfitfiatmia Tarsi. 

By this ia meant a congestion, or chronic inflammatory process, 
afti^cting tbe eyelids; more especially at their margins. The Mcibo- 
uiUn folliok'S are prominently affecicd ; and a viscous, disordered se- 
vri'llon iidbciTS to tbe parts, tending to cause coliesion of the ciliary 
mvnpns. More or less lachrymal ion, in geueial, exists, Tlie eyo- 
^gl^l^^ffi nn* hLontud,i>r deGcierd. lEching, heat, end intolerance of b^ht, 
M« WUaIIj^ pmrnnt ; trnd the genor&l expreaaion ia bleared and unjtlea- 



*tW 4bMu» will nsaally be found co-existent witb Bome vitiated 

' Utint, No. lOGJ, p. 436. Ono iniOTig many. 



SWELLINGS OF THE EYELIDS, 



97 



F 



comiition of iho goncml eyBtom; unci to that this treatment must be 
^ mttinly cKrecItil. Not unfrentTtntly, the conslitiitional virB wJll bo 
fniind of the Bcrofnloua character. If pain, hcat» redneae^ mid otLer 
ordinary cliiiractenatica of the inflntnmRtory pmcess exist at all promi- 
nently, blood is to be taken sparingly fmm the jiart, by scariii(.atii>n 
of the eonjunftiva, vr by [etchefi at ilie inner cantbun. Fit a few 
days afterwards, fomunlationa, incdicatad or not, aro. to be applied. 
Then Blimnlants are used ; encb ns Hnbitione of zinc, or uitrate of sil- 
ver ; or the nng: nitratia hjdrargvri diluted. In obstinate caws, 
counter-imtaliLiti is sometimes nsefnl ; and ibis is V-st eflected by the 
Bpplicaliun of bliitors Wiind the ears. In thildreii, the stale of tlio 
guma and teeth must be looked to. 

An adrfinced fonu of tUie chronic Affection of the eyelids ia 
Bometimea termed Lippifudo. The ciliary margins are red, tLiokened, 
everted, and denuded of hair; and the eye seems to be Burroiiuded by 
an angry red circle. The general expr^-ssion ia consequently very un- 
plerislng; and the patient's disisomfort is also great. Local and general 
alteratives are pTe-etninently required ; but they often fail to prove 
quite ^liftfrLctory, Stiiuidjuitis applied to the pai U are u^ful ; mich 
aa pencilling the lids ivitli a Bolution of nitrate of idlver, and tfae 
like- 
Not unfrequently, ophthalmia tarsi is but a part of a more general 
uSectlon of the eye, of a strumous character. 



Htn-deohm, and other Swdlings. 

Ry Hordeolum, or *S/yp, is mejint n circnmacribed inflnmmatory swel- 
Hag, which may either remain of an indolent and indurated character, 
or wlvanee to suppwatioD. In the latter case, discharge of matter 
takes placCj and discussion sloa-ly foliowe. Very frequently the affec- 
tioEi originalea in a Meibomiau follicle, Eind resembleH an ordiintry 
pimple. The follicle ia obstructed ^ and its contcnifl nccumultite; an 
inflamrafltory process is ih(*n kindled in the perverled part, Buppum- 
tion takes (ilace, and the enlarged follicle becomes the seat of a small 
acute abscess^ 

Here, too, the general health will be found amiss; itnd purgatives, 
alleraiives, with regidaiion of diet, will probably bo required. While 
the BvvcUing is uivjicent, fomentation and light imuUitPs, ov watcr-dresH- 
ing, are snitahle. When matter haa fcinued, a piinelure should bu 
made at the apes of the swelling, for efficient discharge; and then 
water-dreasing is again applied. If a chronic burdnesa should throalen 
to remain, discussion of ifiis will be promoted by pencilling the part 
lightly over with a soluiion of iodine, or nitrate of silver. 

An iullammator}' swelling, simihir to the Irvie hordeolum, may 
form in the ordinnrj' areoW tissue of the eyelid; n-sembiing a small 
fuTunculus. It ia amenable to ordinary treatment. 




68 



ENCVSTED TUMQUnS OF TEE EVELTDS. 



H 



Small, Imrd awellingfs, of a wliitisL colour, very Biiperficial, pain- 
less, atid almojit sUnionaryj occuBionnily form beneath Ibe ijileo;DmEnt 
of the eyelid. According to their size, they are lenned either Grando 
or Milium ; according as they most reAembie a pece of bail or a millet- 
seed. Caubiiif^ defurmity, thty require temoval. A scratch i» made 
through the tliin skin utretcheJ over thain, and the white pearly-look- 
inft RiilHtanpe is BqiieeKed out. No escliarotic 13 neccKaary. Tlie 
wound scarcely bleeds, and heals sinjply, 

WarlB somotimca form on the eyelids. They may he taken away 
by BCisHore, ligature, or cauetic. 




*1j, 10. 



Encysted Tumours of the Eyelids, 

Encysted tumours are of frequent occurrence in this Biluation ; 
more especially in the upper lid. They are usually of Kmall size ; tbe 
contents are white and glairy; the cysl is exLremelv delicate. Their 
site may be either subeutuneous or submucous ; 
on the coiijuncLiVfll or on llie external onpect 
fjf the tarsal cartilage. The majority of the 
patientfl are of the female ses. 

Removal by regular dissection need not 
be attempted; the cyst is too delicate. And, 
for the EameV'HBon, incision, with evulsion of 
the cyst, is inapplicahlc. It is euEGcieat, in 
many eoEes^ to itieise the pa.rt^ to btpieeze out 
the timtenls mid with the point of a probe 
to diBtiirh and break up the tender rytt. But, in some cases, jt is well to 
Apply an escharotic^ so as to ensure the cyst's destruction, find con- 
■equent non -reproduction of the tumimr. The nitrate of silver is very 
amt&blc ; eschaiulic; eiiuugb to atjnihihite tbe cysl ; and uul likely to 
cause fluph loss of Bubalatico as woidd daisy the cure, extond the cicatrix 
unnecessmly, or risk the occmrence of either inversion or eversion of 
the lid by cijniraciionof thccicatrix, incif*iun ibfacilitaledby effecting 
previoUH tension of the psrt. This is dojie by simply slretchini^' tbe 
akin over the Bwelliu^', and culling tliroiigli the aitennniediulegiimenl 
—Inking t;flre to moke the incision iu a direction pandlid to the fibres 
of tbe orbicukris miiBcle j or by evei-tiriij tba lid, ami tben cutting 
through tha stretched and prominent mucous memhrane. Either 
form of procedure is Ihe preferable, according as the site of the lumonr 
happens to be subcutaneous or aubcniijimtjtival. 

Htfptrtrophy of the Upper Ef/elid, 

TW upper eyelid is occnsiionnlly aflected hy hypertrophy of both 
ent and mucous membrane. The swelling is considerable, 

'. H beyttnl tumour of tho Inwer eydicL Thf^ Ud Qvcrted. 



CANCKK OF TH£ £YEL]Ua. 



68 



and oau^s dcforiuity ; it aJao t>ljetruotQ visiou ; and thoro is ati unplea- 
sant piirirann rlisohnrj^. 

By two elliptical inciflionB, a Hiifficiencv of tbe (liseased inleffii- 
mental texture is renioved; and the wound b approximated by sutaro. 
The conjunctival change is siibseqnuntly remedied by scarification, 
followed by the use of fiorbefacients. Or sbmild tbe cuiyunciiva re&iat 
this geotkr mcaiiHi partial ablation of it may be practiced, as in the 
Cftse of tbe integam?nl* 



Cancer of the Ej/etids, 

Muli^ant nlceruiion is usually preceded, in the eyelids, by warty 
formation. The oaly cun; ia by esci&ion ^ early and free. If the 
diseasy be limited, siiffident removal may be efTeclod, yet without 
deformity or exix^sure of the eyehall ; the wound being bo shaped aa to 
come well together by suttire. But when the disease ia extensive, 
and aii operation warrantable^ the pTeventiou of deformity need not 
enter into our thouglits. One parflmounl indication is present — 
removal of all the diaeaticd {lart. That mutit be elTeiMed, at whatever 
■aorifice of to3tiire. Whi^n it h found noeeseary to remove the whole 
or greater part of the eyelids, more esperially the ujjj^ier, on account of 
malignant ulcer, it comeH to be a question whether or not it be politic 
to spare the eyeball — supposing it to be apparently sound, yoma 
writers recommend its removal at once^ considering that the organ, 
beiug deprivt^d of its natural prjtecllou, will be destroyed hy inflam- 
mation. ThtH, linwevL-r^ i^ ont always the ca£C' It iu bettar lo wait 
till this event has actnallj taken pliico, and then to induce dollapse of 
the globe^ by piiuciuritig the cornea^ and allowing the humours to 
escape; this is more safe and simple than immediate extirpation, and 
equifcliy efficient. 

Intractable ulcertf of tbe eyelids — not malignant— are beat treated 
by regard to the stuto of the ajHtem, more especially of tbe dilative 
organs ; and by occasionally touching tbe parte with the fluid nitrate 
of mercary or nitric acid. Sometimes they are of a syt^hilitic cha- 
racter ; obviously dependent mainly, for cure, on constitutional treat- 
ment. 

Cloa^tre of the EytUds. 

By thu term Anchf/MUpharon ie nnderetood, union of the eyelids 
at their tarsal margins; congenital; or acciilental, the reanlt of cica- 
trization after bum or scald. Wlien conjrcnilal, the cohesion ia seldom 
to a great extent ; occupying only the angles. No interference may 
be deemed necessary. When more extensive, causing not only an 
unseemly defurniityf but likewise in terfti ring with vision, aeparation of 
the preternatural I y united jmrta may be readily effected by incision, 




70 L AQOPHTH ALM De. 

Aftamarda, &11 necessary means should bu Ukeii to prevent reunmn ; 
each lip of the wound being made to cicatrize separately, by pfruimla- 
tioD. When the dosure ia complete— a circniosliince of mi-e occur- 
fence — a fnld of the partis should he liret rained from tlie ball, and cut 
thruugh in n bimzirutal direction; ihixmgh ilih ajwrlu re a director it 
tftrcfuUy introduced ; and on it Ibu subsoquont division to tbt? n-nglca 
IS RBfely etfected. The accidental furm is am^'nahU: [o similar treat- 
meal. But greater care is necessary, iu the after nianasement^ to 
avoid reunion. This ia prevenled by the inteqxKidon of dressing, 
frequent muvement of lh<5 piirts — and, if necesBary, by forcible seiiara- 
tiL>n of the liilh by plaster, and tliu ttpplieatioii of suiiie ^eiiily aalrinfjent 
lotion. 

By Sytnthphwon is m^ant adheraon of the eyelids to tlif> eyeball ; 
neldom con^enitil ; usually the result of cicatnKati(>n nfter injury. In 
aome oaae^t I'jc cicatrix is deni^ aikd contracted; admining of no 
attempt at cure. In others, the adhesions are comparatively slightj 
and tber£i is sullicient hixity of texture- In these latter, the lids are 
tn bo liberated hy uircful di-sscclion ; tlieir aeparute cicatrizatiuii 
being nfl^rwArds careriiUy attenrled to. Reunion is much more liabli> 
to take place in Rvmblcphaicn iliau in ancbyloblepharon ; and is best 
prevented by frequent moliou of tlic eye, by proper dressing, und by 
the occnflioniil inlrodnctioa of a probe to separate the new adhesiona. 
The (emporury iuKeriion of an artificial eye liaa been sutrgosled ; but 
ercn Ihe moat persevering exerlious have often proved unsucceasluh 

Zaijojifii/iahios. 

Lagopbthaluiofi, or Hare-eyp, means an inability lo close the eys- 
lids; and the eye being deprived of ii^ natural proleclion is exposed to 
the action of the aii' anil uliier external irriljuita, wLitb may cause 
inflammation of tho canjuuetiva^ eventually toruiiiLating in opsicrity of 
the cnrnea. The disease often rcauUa from paralysis of the urbioularii 
Diusck' ; more frequently it is catised by retraction or Bbortening of 
the lid, arising from contraelion following abscess, or bums and other 
injuries, Scmetimoa it proceedfi from cold or other causes acting upon 
the facial iitrve in ita Irftnsil ur dlslriljutioii. 

The troiiEnitnt varies accortlinj^' lo the eauBo. When the alTection 
arises from paralysis, blisters, friction, electricity and strychnine are 
appropriase ; when from retmction of the lid, division of the cicaLrix 
may Iw of use; and when from affection of the facial tierve, iLjeebea, 
bli.sters, and slimulauts in the course of the nerve are lo be employed. 
When it is caused by cerebral corigeflliuu, untiphlogistic reiuedtes are 
to lie had recourse to. 

Ptfiirs. 

PtObifl is a falling downwuids of the ni»per eyelid; prududitg no 



TRIf.-HUaiS, AKD DlSTlClIUSlS- 



71 



int'onsiderjiUe defin'uiitj, and aerioaslj" interforin^ n-itb visian. It 
amy foiiatitule a i.iLT«a&« of itself; or It may be but a aymptoni of 
Berioiw a£foctioii of the brain. When origiDal, it may depend on 
debility of ilic elevutiug musclei or un miperfluity or iliickeniDg of tiie 
integoment; or it may be coQuected wlLh both of tbes^ ciriruuiatHucc;!^. 

Bednmlmacy of xnte<^iTuent ih eiiaily got rid of, by removing a suf- 
ficient tx^rlion, eillitir by knifi? or by scisflora. Atony of tlie mupciu 
may be overcomu by stimiilaut frictions, tlie passing of electricity, or 
the endermio use of Blryclinine. Ordinary means tiaving failed, an 
operjdiim may be had recourse to. A larg^ portion of Jntegnment it> 
reuiQvtJ fruui the eyelid, and also frum a currespondiiig ijortioii of tlic 
eyebrow; the two raw sarfacoa nrc then bronglit Into appusitioii by 
suture^ and wlitn union boa taken pliiCi; the lid will lie elevatt^d by 
the action of the occipiio- frontalis muscle, to &\di an extent aH to admit 
of useful vision. 

La the eecondary form, dependent <m adection of the bma, treat- 
ment iniiat uf cuurae be directed to tie cerebral disease. 

Trichiasis, and Disticftiasis^ 

TrichiasiBdenoteainveraiouof the eyelashes, whereby much irritation 
ia induced uu tlie surface of the eyeball. The inversion may implicate 
the whole tilia, nr only a few. It may ticciir in either lid; but is 
inofit frequent in the upper. The position of the eyulid itnelf h not 
ftlt«red- At first tbero ia merely inconveniunoc ; but, sooner or later, 
an inflamtnatory jjrocesB is cfliabliahed on the surf^ice of the eyeball, 
and con^quent danger to vision may prove great. 

Treatment is either pallialive or radical. The former consiafs in 
eviiI?iion of the erring cilia, from time to time, and mitigation of the 
irritation and JndammaLioii which they may have oceu^iuncd. Fur 
evulsion, a. pair of broad -pointed fon;epa with iheir opptjBiiig suj-facta 
in accurate contact, are re<|uired; for the havra are usually lH>tJi 
slender and li^bt coloured; and the assistance of a lens is often 
net^essarv. This meth(Hl is on the whole nn satisfactory ■ and is only 
ap^ilieabJQ to llio»e cases in uhicij but a few of tlie cilia are in 
faidt. 

To cdecl a radieal cure, it is casouLial that the liishi^a be not only^ 
removed, but that their non-r*:pro(.lu ration shall be inMirtd. One of 
two methods may be rollowe<li The errant, ciha may be plucked oul, 
and their bnlbs destroyed. Or the bulbs and cilia both may be re- 
moved by cutting instniraenlH, The ionm-r methoil is njiplicable to 
the partial triehiabi^; the latter to the eouipkt«. If die former be 
oboson, an iaeistoa la taado with the point of a laacot, on the frco 
margin of the lid, down to the roots of the inverted cilia; intvj this 
litde oiH?idns a needle or another kncet, coated with powdered tar- 
trate of antimony, ia inserted — allowing it to remain so that ita coaling 




n 



ENTliOFlON. 



may <1iiffiolve Uiere ; aud the lukira an? tlieo pulled out A araalt 
puHtnle forrnR, nnci ihc buTba nre destrnyed,* 

When it is our otject to remove not only the cilia but their bulbs, 
a hom spatiik is introduced LeiieaLb the lid, an incision ie made 
down to Ilia tarsus along Ihp whole Itngth of Ihe inverted portion, 
parallel to, and iibiiut a litie fmm the ciliary margin, to wlitch it is tu 
be connected al each eslroraily j the ciliarj edge is dien to be laid 
h*ild [>f witii forceps, ami the integiimeTitK carefully ilis^ected from the 
cartilage, so as to include the Inlbs without interfering with the mucoaa 
edge of iho lid. When the part eiuiitri^es, little deformity will result. 
Or, the mar^ii of the lid is laid hold of and stretched by the fingerH 
of the left hand, or by forceps; ami by the stroke of Bciawrsj or the 
Bweop of A fine biBloury^ the reqiiiaiic amount JH taken away. By 
operatino; in this way, more ileformity will be profbicod than by the 
fornier plan; t^ut by either the eyeball will be freed from a continual 
source of irritation. 

By Distichiam ia understood a row of supernumerary cilifti gTi)w- 
ing- inwards, and causing the same unpleaaanf and untoward rci^ultsaa 
the foregoing ftfFeccion. The same treatment is reqinrcd jis for IrichiaBia. 
But mi^re cart-fid examination is e\pedi*til; inasninch as the observer 
is apt to be deceived by seeing' ihe ordinary eyebiBhes of their normul 
character, and, even when the lid is rai[?ed and scrutinised, the paucity, 
BlimnesK, and paleness of the stray lashes niny often canse them to be 
overlooked ;^a scriuus matter ; for unleas iLey be noticed and removed, 

the inflaminalory pn>c;tBS will n<it only become cHtablished^ hat will 
pi"ove nnconiroUablo- To dct«ct them readily, the lid should he inspected 
laterally, as well aa in front, and the patient should be desired to turn 
bis eye in differenl directiouSj ko as to form a dark back-ground of the 
irid and pnpib 

Eittropion. 

TbiB ia turning in, not only of the eyelaaheHj but nf the margin 
of the eycliJ itself, attended with all the unpleasant consequences of 
tricbiasisj in an aggravated Ibrni. It may 
be temporar}' or permanent. In the former 
case, it is the result of inflammatory swel> 
ling of tlie tyelid ; " the lumefiiid coiu'unc- 
tiva prpKsing out the orbital cdgo of tbo 
tarsiiB, while its ciliary margin is turned in- 
wards by the aclion of the urhicularia.'^f 
When permanent, it may depend on relaxa- 
^'''' t ion of the integitment of the lid, whereby 

ditiplaoement inwardx of the ciliary margin is both peradtted and 
• EilinbiiTj^h Monrhly Jimmri, April 1941, \\. L'SO. 




Fig. n. Entm|tinn, iilTKliii^ hr-Xh pjclid^. 




RNTUuriOK. 



73 



fnTonretl ; nr on ocm traftion of a flioHtriT on tlie conjiincTival aspect of 
the liJ, wLereby llie ciliary mar^ii is Jiieclly piilU'd innurds ; i>r ou 
a perverted form liimn^ U'en nssiiined by tlio tarsal earUljige itself, 
in cnnsequence of ophthalmia tanti, psoniphthulmia, or other chronic 
diaeafle, Eitlier eyelhl, or both, luay be afrecied. 

Jt is evident that (rcfltment must be both cnriy and auilahle, if wt: 
wSsIi to Bftve ibe eyebnll fmm Berious injury. In lh« lemp^rury form, 
it will be Bufticicnt to oppose invcrBitm by ihe apiilicalion of retraclia^^ 
planters, frequently renewuJi until the cauBc of disptacement has been 
removed by treatment directed towards siibjugatioQ of the iaflammatory 
procesH and djsjwrmon of lis swelling- In the permanent Form, opera- 
tive interference b essential. If ihp integEiiui^nL be rt'duiiJaut, a por- 
tion is to be n/nt»ve<K And it is nticeeaiirj tlialf in ilic first instance, 
a very careful examination bo uinde, to determine how much in to be 
taken away, so as to insure rectification of tlto |»ositioa of the eyelid ; 
while yet we avoid removing an unnecewiary auiouut» and eo canning 
an opposite condition of the parts — ectropion. A horizontal fold is 
piiicUed up by suilablc fon;cps, or by the Gn^-crs, and in removed by 
either knife or soisBors, The odg'^s i>f iho ^onmi aro then uiiilod by 
HUtures, and aiiiiesion follows. "Rscbarolics may In* employed f*ir the 
same pnr|>f>sc ; bnt they art inferior to the cutting inalrmnente, being 
possessed of no eiactitnde as to the amount of texture to be destroyed. 
Siilphnric acid is the most ofloclual, not only destroying skin, bnt con- 
solidating' Lhe areolar tissue, and prixlni^in^ eversion by contraction of 
the granulations. ' When acid is used, a piece of ronnd liard wood ia 
dipped into it, and applied behind tbe tarsal carlila^iri a line exlerd- 
ing ibe whole len^lL of the inverted portion. Cold water dressing is 
applied, and in a few days the slough separates, the granidaliona con- 
tract, and the lid is reslored to its proji^r pnsiliOn. The eye, however, 
mnsi be carefully guarded from 1be acid, dnrin;;^ itn iL[>plicatiou^ by a 
jaece of wettoJ lint introduced between tlio lid iind the glpbc. This 
action of Milphnric^ acid cnoBca in ^en^ral exipiisit^ pain^ and h only 
applicable to cases where (he patient will not MJbmit 1o an o]>eratioD 
by shaq^ instmmeijts. 

When the disease is dependent on a perverted state of the cili&ry 
Diarpn and tarsal cartila^, one of two methods may be adopted. 
The cilia and their bulba may be removed, aa for trichiasis ; c».TO 
being taken to leare the puncta laebrymalia intact. Or^ by such 
,an operation as the following, an attempt may be made, retaining 
the eyelasLeSj to liberate and reetore them to their normal position ; — 
" The patient having I «en plactd in a pitting posture, and the head 
supported by an assistant, the inverted lid is sepuraied from the globe 
of the eye by meaoa of the finger or a abarp hook ; and then with a 
pair of strong scifaors, two perpendicular incisions are made through 
the tareal cartilag'e, each abont a quarter of an Inch in length, tlie 
one U]>on the temporal, the other upon the nasal side, avoiding the 





74 



KCTBOPION- 



imnchim, anil inolmlin^' the wbola iiivci'teil portion of tli(> lid. This 
part being now everted, and held in that position, the two perpendi- 
cular incisiona are connecteil hy & horizontal incision upon tlie con- 
Junctivid surface, cloae lo the ciliary luargin, by meaus of b acftljiel ; 
cuttlo^^ throu^'^h Ihu conjimcliva and tiirc^al cjntila^^f and Jeiivhig ihc 
inverted ]>ortiori of the margin nnitod to the roet of thi^ lid men-dy 
\iy t\\& integument. And esjiec^ial rare in triken tl;at the? knife does, 
not penetrate through the skin/' Water Ureaslno; in appHe-l, And 
** the tniccesH of this upeialion de]jends in ft great measure on thir 
edges of tlie inciMon being prevented from uniting by the first inten- 
tion, particularly the horizontal incision n|.ion the conjunctival Ririace. 
ThJH IB eflcrCed hy everting the Hd otcii^ionally dnriiig the first few 
days, and by touching the edges immediately aftor the operaltun with 
the Billpliale of copper, so as to caune ihem to sii|'purate and lieal by 
granuhitioii-"* Another operation for (entropion coiisistH in making a 
pa Fijendicul a r section of the lid, with scibsoi's, at couli cauthus, from a 
quarler to luiU an inch long ; taking care not to wound the punuluoi- 
All elliptical portion of skin ia tiien removed from the outer aurfjce of 
the liU, Two tT three llgnlnres having lieeo itilrodnced thi'ungU the 
skin iit the tarsal margin, the eydid is everted by means itf tliem, and 
drawn up towards the eyeiro^v; in ivhich position it ifl retained for a 
few days, by the ligatures being fixed to the forehon^d with a Ktrip of 
adhesive plaster. In llio meanltnu', the exposed mucous meuibmne ia 
covered willi a piece of \velted lliit ; and as Llie pifr[)endR-n[:ir indsions 
heal by grumdatiou, a snfficient degree of evL'rsion \vill be produced. 

Mr_ Tyrrell recommended tliat the lid should be merely divided at 
ila centre by a f^iiirrlu iwrinnjdicular incisiuii. The presKiire cjiused by 
the eontraeted cmribLgc \\i\s thus relieved ; aud as the wound, shaped 
like an invcrlcd A, became tilled by griinnlalions, very little deformity 
would rcBuli. Bulb operaiioija aie only a[>pliealile Lo tai>cK where thu 
disease nrieea from a cnjitrat-ted Btutc of tht c^rtilfti^c!. 



\ 



Ectropion. 

Ectropion denotes an oj^posite cundi lion of the eyelid; its eversion ; 
and Ib more frequenLly met ^vitL in the lower, timn in the nppcr ltd. 
The coniunctival liAiing is exposed, the eyebdll is partially denuded, 
and much deformity ia prodotTd. Afler a tinje, ihe exposed palpebral 
conjiinctivu loses much of its membranoUB eliaracter ; the suri'aco of 
the eyeball beeonica irriliible, iniiami-a, iind nijdergoes change of struc- 
ture — probably f^itid lo viiiion ; and a dej^ee of I'pijdioru invariably 
exists, in consoquenee of Ihe niitnral coiiiho of Ifie Uchrymal secreiioQ 
luwards the puncla being interrupled- The mal-powtiou moht fre- 
quently rcsnlta fi»m conlr.iL-liim of cicblricea of the integument ; and 
these may L'xist in llie eyelid or ils immcdiale vii'iEiity, In Ihe corrcs' 




ECJTBOPION- 



75 



prtndino: nhpf*k, nr exUinsively on the fiicc and neck, as after severe 
buTUB. Tlie lower eyelid is the more frequently affected. The 
cicatrix may fi>Jlow a. hum, wound, sloughirg absccBa, or eifoliation ; 
the Crsl und last ftre Ihe most iinfAvoiirahle. 

Ectropiiiii, liiiwevor, ftri»«s fronj other causes ihun tlie conlroclion 
of florcB. Simple rolasAtion of the lower lid will prodii(?<' it ; tmd thia 





Fig. Ifl. Fig- tit. 

may depend on ElabhiiieBH and fBd'iTidnncy of nil the ccnai'oncnt tejttnron, 
or on atony only of (he filruH of tho orhiculftrie. The last cireumBUnei? 
is no unf^oramoii nmirri^ncft in old peojjie. Frt'niipntly ^'Ctroidoii is 
caused by a. fatilty comlition of tlie conjunctival lining of the lid ; whiuli 
is the sojkt of swelling, of either an acute or chronic kind. And it irt 
well to remenilxjr liow general inllainmalory Bwcdiing of the lid in ivhlts 
to uau«e either iuverBiou or everBJoii, accjniing Co the accidi^nt of dis- 
placoment ] jnat as o, eimiliir condition of the prepuce may bo tlic emise 
either of jiliyninhiH or of pwraphyniosifl. Eversion la uo nnoomtnon 
attendant o\i piinilent ophthalmia; from the acute and ijjreat swelling 
of the lid, more especially of its conjundivul lining. U alwi resnllfl 
from an indolent enlargement and thickening of that membrane. The 
accidcntnl divifnon of either tianlhiis, loo, may cuusu tl ; llic lid beci>ni- 
ing looBt^ and pendiiloua. Or it uiuy arJHo from an elongated anri 
irrepnliir wtflt^i of the tftraal eaHilngo. 

Treatment necessarily varies according to ihe nature of the caneCp 
Aente swelling of the eyelid and iU lining h Eiibdued by the iiMml 
meanB. Chronic enlargement of the membrane is tirBt trealeti by 
scarifiualion, and astringents. If these be resisledT the redundancy 
niiiy be removed, either by corvetl flci^sors or by caiialic j the former 
obviously to be pi^ferred ; great care being taken lest, by tlio removal 
of too mneh, enti-opion be prinluced. Atony oi" iiaralyna of the fibres 
of the orbiciilari.s may he combated hy the nsnal means; but, gene- 
rally, this form of tht affection, occnrrinj^ in thotw of lulvanecl years, 
may he regarded ^mply as one of the many signs of decay, and irremedi- 
able. When there is elongation of the tarwil cartilage, or rednnilancy nf 
the whole lid, abbreviation, tiufBi^ieiit to reNtnni nominl position, is efToctml 

yig. IS. Kcrm^ii'^iir atFprtiii^ (li£ u|>per I'^'i'iiil ; ihc ccdutt itf ex^fiiatinn. 
M^. 1*K Eclmpion, nflcctinii: the lower eitflW. 





76 



Kl'irHOBA, 




hy a simple operation- Ttjwarde !lie centre of tlie Ijcl^ a triang-ulnr 
pottJoD of its whole cliiokness is 1o \tG removed in the form of tlie letter 
V ; the margins of the wnunrl are br(>u(,fht Log^tln?r hy siilure, a proper 
coTiipresB ifi applied, and when the parts heal iho IM will le in clnaj 
appomlion to the globe. In the cast? of fanlty cii.^alrio*^s, the procedure 
iH more difficuU and less promising'. Occasional ly^ llie simple <livifl"ion 
of a tight adhesion may suflice for llberhlioji aiuL rc'placmnent. Bui 
generally, there is loss of Biibetanise contJected with the cicatrix, ar.d 
consequently simple iiici&ion proves iujideqnale. In the case of a 
nuKlerale cicatrixj at some distance fnjm the ciliary 
uiargin, amendment, if not complete restoration, 
may be aceompliahed as follows : Sui>poBing the 
luwt-r eytlid lo be affected, aV wound is made, 
through (]io inlogumont only, the ^pes poinling to 
the eheek. By means of the knife's jxiint, the in- 
eluded sliin is Treed a Htlle from its areolar con- 
nections ; and resilience upwards is favoured by the 
QeoBflsary luaiiipulalion. I>ifi}dacemenl iijfwards is then delinilely ee- 
onred by bringing together laterally the wound tliat remains lieneatl), by 
means of sntnrcs. In not a few caaca, tlitrt ia not safficienl Iwxily of 
parts to admit of tlnn_ Under aneli eirunmstant^es, somiuhing may be 
done by iiiciaing the eyelid, aad replaciJig its ciliary margin ; Ihco filling 
up the chasm beneath, which neceHtarily resulla, by a flap of iutpfr^inient 
borrowed from the adjoining cheek- When ectropion has resulted from 
accidealal wound at the canlhus, rertilication is easily obtained by 
reunion of the divided parts ] the margins of the cicatrized wound being 
made raw by parings and retained in accnrate appotdtion by suture. 



Vig. TO- 



Btcpharoplasiies. 

When either eyelid haa been partially or totally destroyed, by 
injury, or by disease nut of a malignaDl kind, an attempt n:ay be miide, 
not without good prospect of success, tsj supply the deficiency by u euit- 
able flap brought from the immediate vicinity. No precise nilee can be 
^ven for eucb an operation ; the details must neceflsarily vary in each 
case.* 

TIL APFECTrONfl OF TIEE LaCHRYWAL ApPAtATUB. 

Epiphora . SfUlicidium^ 

Epiphora consists in an increitfed secretion of teai^, which flow 
over the cheek. StilUcidimn lachrymarum depends on some idTeclion 

* Liriidim jJruL EdiabuTgh Monthly .\o\aaBl, 18^, p. Ikr^, Cyclopa^ici of ?rficti<:iil 
Surgery. Svb rotB. 

Fig. MO, Plan of this operatiun ; the doltsd line marking the ^ffiginnl •tiumi ; the plain 
hnp roprcsflnting th« flap nf nkin in Elu new uid e|i>vat4'l ]>OF.iti"<i. 



AFFECTtONS OF THE f-ACnUYMAl, tJAr*. 



77 



P 



of th^ excreting laclirymatjjry apparatus, which prcTenU them from 
laHiie: up the leara as they are secreted. 

The n-atery eve may be either congeuiLal, or tlie result of injury 
or disease* It is best treated by means of aatringent collyria; by 
weak Molations of nirrate of BiJver, or wine of opium, dropped upon ihe 
eye once ft-ilnj ; or by espuaing the eye to the va|xnir of hiodannQj ; 
And hy using at the same time Kume weak red precipitate ointment to 
the edgen of the lids at nigbl, when there is any derangeineut of the 
Meibomian Becretion. 

In oil cases, not prominently connected with some more important 
affeetron of the eye, the stale of tbe general systetD must be cnrefully 
Jookeil to i fur it is eJtrcnifly jTcjbftble that uo slight duclensiun from 
healtli will ho found ; and, unless thlfi he remedied, nil IhcilL Ui^afment 

will prove of comparatively liitle avail. When a valcry eye results 
from a contracted etatc of the puneta, these are to be diluted by means 
of fine probes, or a stiff brititle. When ihere is relasatiou or atony of 
the If^chrymal sae, then stimulating' injectjong or collyrta are to be 
uwd. Thi^ae ore thrown into the sac by mi^aiis of Ancl'ti i^yriuge, 
ihrongh the puncium. Octaeionully, a emidl hliater applied over the 
Rftc is of uw- Wben the nasal dnct is obstructed, measurps must he 
taken to effect its clenrauce. Ofttn the watery eye is hut a symptom 
of ^neral ophthalmia, and is only to be cured by its subjugation, 

jXeroma denotes an oppoHle eondilion ; a rirynesa of the eye, 
dependent on deficiency of the lachrymal secretion. Frequently it is a 
temporary prelude to leaver affections of the eve, of an inflammatory 
naUire. When it occurs eingly, and persisls — a^ is but seldum — 
restoration of the secretion ia to be courted by ordinary stimulant means. 



[ftfiaminatorif Affections of the Larhrr/mal Sae, 

The areolar ttAsuc over rtc: lachrymal Sfzc aometimes ia the seat of 
an inflammatory process ; while, in tlie first instance^ the Kfle Itself iq 
free, A red, ilcEiy, iizdnful swelling' exists at the comer of the eye; 
tinil tbe system sympathises slightly. The cause usually is esposnre 
to cold. Purging, and antimoniala internally, with low diet, and jien- 
ciiling of the affected part with nitrate of silver, or tincture of ifxiinei 
win ordinarily suffice to obtain rti?wbjtion> If ihey fail, then local de- 
pletion by leeching nmflt be bnd recourse to; ibo leeches hein^ applied 
over the part iti^elf It is obviuusly of much importance to be early 
and active m Fuch treatment, ■ so as, if possible, to prevent involve- 
ment of the lachrymal sac. If suppuration should occur, a veiy early 
incision sbould be practised; lest perforation of the sac take place. 
Not nnfrequently, ootwitlstandrng every precaution, the sac in involved, 
and suppurates acutely. The same treatment is nectfiSrtry ; an early 
evacuating incibion, or ejjiarsement of the spontaneons opening; and 
light water- dressing aflerft'arda. The oi#ning granulates and heals j 





78 iFFECTioya of tue lacuryhal sac. 

(tnd HBually the Lroatli in the Bfto closes, It^aving its Ciivity utioc- 
cluded. 

TAe L(Tchri/rrtal Sac may itself bt tlie primary seat of ncnti* iiiflamma- 
lion. This may occur iUiojmOiicftlly in those of wt^ak systom ; or in any 
one, after expcisiire to cold. A Bmall, bard, rrucniQscTJbed, and verj \}A\n- 
ful auiflliiig in foriuL'd Tjulyw the teiidon of the orbiculBris muscle j the 
BtipcriiDpoacd intpgnineiita soon liecomo rod; tho eyelids arc mora ur less 
rederajitous : the corTi-spoinlin)?; side of the nofitril is Hrj'; and tht* Bystem 
Bympalhises consideraLly- Tlie swelling increases, often almost obscur- 
ing the eye ; an<l severe head^ich usually is complained of. The course 
of tLe tears is obstnicltd, by the tumid stale of the dut'l'a lining mom- 
brane — inflammation iiiiving esieinlod lo it — mid they find Lhoir way 
ovcT the clicit'ks. Suppuration occurs j iitid, eooticr or lutor, the miitlor 
is disrhni^ed extemnlly. Then a slow renovory may nnsue ; the njisa! 
duct becomes a;;ain open, the tean? resume their proper course, the 
suppurated aperture gramibites and hcids. Or the ohslrucliuu iu the 
nasal duct remains, the tears do not reach their wonted outlet, the 
aperture contracis but does not huiil; aad the condition of fistula 
laohrymalis is estjibllflhed. In severe and neglected ciiRcs — more espe- 
cially if occnrriug in n d^bilitnted frnme— the siilijacent jwrioateum 
may be destrnctively involved, and ledious exfoliaiion en^ue. 

An tipldogi sties are ohviously JemanJed here; leecbes over the 
inflamed sac^ wami amxiyne foment at ions, and a fidl dose of mi^rphia 
at night, to allay pain and procure rest. These ought to be used 
early to avert snppurftdon if possible. Whon matter has formed, it 
must be pviifiuili'd at nnop- Tin's is dorip hy ititrihbuing a bistoury 
into the sac, below the teud(m of the orhieidaris, which ought to be 
rendered prominent hy drnwing the lids outwards. After e\'acnalion, 
light water-dressing or poultice is applied ; ujid the sac, after a time, 
nia.y he oeeasioually syringed witb warm water. We hope tliat tbe 
niombranu uf the duct will dniy recn-cr from iti lumid ai&tv, that tbe 
iiarnral eonrse of the kelirymal fluids will be restored, tuid tbat tbe 
outwanl opening in the sac will close. 

A chronic tijfecfion of the lachri/jucrf sac is not uncommon ; the 
vasmdar process reaching no higher than congestion, and limited 
ttlmost entirely to the lining uienjbrane. An indolent swelling occurs 
ben<.'ath the ten<1on of the orbicularis, sofl, fluchiiiiinjj, co[u]taralivtdy 
painlesfi^ nnd ennnhle of heiiig i?mjtlieil by pressure- Ibr tlio puncta 
remain open, and through them the puriform secretion escr([ies upwards. 
Tbe puaaaL^e downwards is ohstnicted ; and, ind<:edj this cir^juuistiiace 
Beems in most cases to be the origin of the malady. 

Sometimes this chronic dislension of the sac is the result of an 
ftculo or fiubucute nll^ick. In other caaes, it is chrooic from the fii^t ; 
and in these, Ibe state of the general eyeleui in UHiinlly unRU-tisfuctory. 
Tht're is a conslant liabilily lo acute accession, from but slight causes ; 
ind when such an aggravation does occur, the progress is likely to be 




FISTULA LACHiaUALIS. 



71) 



p 



p 



rai»iJ anil untoward, 8iip|fumtion and outward dischat^ lake place ; 
and fistula InL'hiymalia is (.'filabli^li^J^ perltaps witb nuerusia uf lUe im 
unguis. 

Tn^ntmenl consists tri projihvlftclic cure, so kr to avert eiii^h unto- 
ward evpnta; in attention to tht! gooGral health; in mainlttiniii^ a 
compiirativcly empty sinle of tbo eat-, ^ly uccational pressure; and in 
tlie 11^0 of etimulaiil injtctioDs, collyria, or ointmenU* Sumetliiit^H 
veBJcfltum over the sac, by nitratG of allver ur tincturo of iodine, is 
of use; at otter tinjcs, the apphcatiou of a few leeches will prove 
aerviceahle. 

It ia in such cases that Anel'a synnge is of mofit use ; lo clear out 
accnTniiUted discbarge, jind to convey alterative and Bliuiulatiiig fluids 
i(] the vnngesled mtmhrane. Fur overcoming filinclural ubulruclian 
in the nasal duct, any euclk injection is quite in^uJcquule. 

Hnw this condition ie prodnced, haa fllroiidy been explained. 
ObslJ uction takes plate in the nnsal dutt ; the la(;hryniikl »lc inilamep, 
suppuraiep, and ulc^mtefi — the ulccratod 
aperture tUtchargiiig externally ; and the 
wouiid, only contracting, does not heal- 
Thia train of events may originate in the 
lachrymal passages, and urnially does en. 
But tire origin may 1k^ in the subeutaiie- 
oue ircohir liGSiii>, aa a\tv.iiAy state*! ; or 
in the hone and [»eriost«nin, in thnse 
with a merciirio-fiyphililic laint of HyHleui. 
The greater number of cases, however, are of a Bimple nature ; origi- 
nating in the lachrymal passages; and iuvolviiig (he deeper parta 
secondarily, if at al^ 

The c^eiiLial parte of the disensi: jirC| obKlnn^tiun in dm nasal 
dnct, and an external opening in the hiehryniul sac. In treatment it 
is our object to close the latter; and that can be done only by remov- 
ing the former. To this end, an operation is necessary. The patient 
having been seated on a chair, with the head bupportcd, a narniw 
ahaq)-poinied straight bistoury is inserted into the AMuIouh ojiejjing 
beneath the orbicularis tendon ; and is not only lodfi^cd in Ihi^ fioc, but 
pURlied into the* osaeous nasal canal as well. To necomplish tbis 
dexlcroualy, rofcrcnee to the anatomy of the [farU is nectt^sary, in 
order that the penetrating instrument may receive the requisite direc- 
tion; downwartls, a lillle backwards, and a veiy little inwards. By 
the bide of tbe bistoury a slout probe is passed down; and as the 
former is slowly withtiiaun, iht Uttev is pnehed steadily onwardH^ 
until it has overcomo the obstrmjliiiu, and U felt lo fnnch the fiimr of 

Pig, 31. Flitolfl tacbrTinatie. Tho chranlc ota^a oBtabUihed ; Uid the ipf-rtnn urult. 




"^*iWi"^,;!)BW^' 



FH5.2L 




^ 



so 



FISTULA IxACnynMALlS. 



tlie noHtril, To effect Uiia peTforatioTi, a lihle force 19 Roniolimes 
necessary. A few drops of blood, escaping by the nostril, prove 
re-ehtablishment of the duct complete; also, if the patient be made 
to eipire forcibly, while (he noalnla ore shut, air niid L]i>m1y mucus 
nill be ejected upwards through the duct, if the prube have been 
Avithdrawun 

But it is not enongli tbat the knife and probe procure n t(?mporary 
re-efitablisliment of the canal Tliis mns! be kept j^ermanently open. 
And to accomplish this, stj/les — or amnn bou^pea — are emjiloyed; of 
variofis sizes, and laade of Kilvcr, One about the thickness of an 
ordinary probe^ and Gufficienlly long to reach fram the upper ^ound 
to liie nasal opertnre of the duct» is lodged in tiie canid ; its flattened 
^ bead resting on the intpgument. No fixed size can be defined 
(C\ as generally siulabla fur the commencement of the Ueatraent, 
It is enoiigli if the style pass easily, after withdrawal of the 
ordinary probe. Havhig been hidged, it is allowed to remain. 
After some bnurs, the usual relenting of the presence of a 
fiiivii^n body la eviiiceii. Tlie part becomes bul^ puinful^ uod 
finolli^n ; BtilJ, the exciting cjinEe is not lo be removed; tho 
style IH left untouelied. Fomentation, or a poultice, and the 
rain^r general antiphlogislics are employed; and usually, after 
a day i>r two, the infj^immatury signs sulwide^ the stjle feels 
*' ■ loose a^^aiu in its site, and a piimlent discharge escapes freely by 
it. After » few days of quietude, the eriginal atyle is ^xitlidrawn, and 
ouo JL eizti largL'r gently Biibetitntefl. Thi»;, in itn turn, gives place to a 
third; and so on; inilil one is pai^sed of snflieient, liidk completely 
to occupy the canal; the paasan;e being; synn^d once a day with 
tepid water, to keep it clcauT Tliis la^t ttyk is worn for eome con- 
siderable time, natil there is good rcast>n to snpp<ise iliat the normal 
culibre of the passage is fully reiiLored, and that its lining inembraTie 
has returned to a tolerably eimnd conditiim. Then tho instnimGnL — 
whifh hail only bet-ii fuken out occiiKiiinnUy, fur the pnr^Mij^ of beiny 
cleaned and replaced — is withdrawn, and a sniiillcr substituted. This, 
after having been worn for some days, is jniccceded by a less ; and by 
this gradual ahstraclion of the stiniuluB, relapse is rendered improbable. 
Then, if tho tears coniiaue to flow naturally^ and all el>« seem favonr- 
ahle, the nae of the instrument may be wholly abandoned ^ and the 
external apoHnre, now much eoiitnicted, niJiy l-e permilk-d and encou- 
raged to clo-e entirely. Fre<[iieDlly no aid is necessary to secure this 
latter event. But sliouhl a small fistida threaten to prove obstinate, 
the touch of a heated wire, or point of caustic, will UBUally effect its 
contraction and closure. 

At one time, tubes were employed instead of slylea. Ex[>erienco^ 
however, has declared ihein to be inferior. They create the J^amtf die- 
turbiince m the pari, are apt Ut become obslmcted* equally require 

Fi^. 22. Style for tlie ladiryniol dui-L 




OBSTRUCTION OF THE NA8AL DUCTp 



81 



occasJotial removal, and, id fiome coskr^ their attempted removal has 
becD aUcndnl with llie ulmost difBciilty. 

At one timt^, !lIr<i, It wns no ui^commou praclico tr> hook a more 
ilirecl roiid In ihc* nftaal milkt, tliitti tlitnii^h ilie olisJnicterl Inclirymal 
duct ; by pejforalion of the oh urgiiis. This destrnclion of utiiiuiiJi- 
eated t^xtiire, however, ia in the present day very proi>erIy deemed 
imwarran table. 

If ntcrosia accompany the condition uf fianila laciirymaUs, fifulia- 
tioTi miifit be patictilly awnit^d ; for not until the flouil portion of hone 
has bpf-n throw;* nff^ can the f^oft piirts lie (^xpecteii to heal. At the 
same time, conBtitiilioiial tre[itTiK.'fil will cerljuiily be Decefisary. 

It ia well to remember that fistula laclirynialis may be flimidnted, 
tolerably clf»selyj by maligcanl disejisc. A aiedull.iry Lumoiir, or a 
mulignant potypne, fonneii in connexion wiiii the nasal pasaages*, may 
project towf^rda the surfiKic at the intitr ai^^le of thb eye ; UEid itn Urat 
protnrnence^ yet covered by the Ktrclched and iiltctiiuted iiit^^'giiment, 
may occupy iht esact locality of the laL'hr>'m;kl sac. Bnl a touch of 
the part will evince elasticity instead of finetuation ; a glance at the 
nostrils will shew the true i^eat of the disea^se ; and the cachectic face 
and general appearance will sa flic iently testify to Ihe mali^nanl character. 



Olatruclion of the Nasal Duct. 

"We can reailily underatand how this should be a not unfi-equent 
result of an inflammatory pmcesa in the lining membrane. The mem- 
brane is at first turgid by soft exudation; and this narrows, and 
may obHtrnci, the canaU Such obstruction is temporary in its nature, 
and capable of yielding to ordinary treatment, wiicreby abaoqition of 
eilranf'oiis deposit may ho obtainpd. But if the process roiitluue, exu- 
dation becomes more aud more densCj and more enduring; partly 
mucoUK in ila site, but chiefly submucous; Jind by conthumnce or 
aggravation of such structural cliaiige^ diminution and ob^lruclion of 
the canal are rendered plainly inevitable. 

YijT iha minor form of objttniction, rectification of the general 
hea-lth, connter-irnlalion applieil over the part^ jind the use of porhe- 

facient collyna or injectiotitJ, will ordinarily bufGce, In the more 
advanced form, the KtiniuluB of the lodgraent of a foreign Kubstance in 
the part iB essential to efGident restoration by ahsorplion. In Bome 
instauceBf ihis indication may be fulfilled without incision ; by pasaing 
a probe opwjtrdi^, from the naeai orifice of the duct. The probe, G^^- 
touVtj beat nearly to a right angle, at alwuit three- four tha of an inch 
from its point, is passed carefully along the floor of the nostril, until it 
arrives below the anterior extremity of the infuLior turbinated bone; 
thi:u its [^>int is directed upwardt^, into the ciumh This niJinipulatioii 
ia alwayit douhiful, in the Srst instance, on account of the valvular 
pnfteclion by wblcU the uaen] orifico uf the ituct is guarded, and which 

Q 





82 AFFECTIONS OF THE LACHRYMAL GLAKD< 

most be forcibly btuk^D up; often it proves most difficult to the 
eurgcon^ and lioth tcazing und painfnl to the patient ; not UDfrequontlj 
it fails ftltfigelber. It Fhoiild never be attem|)icd, unleffi after repealed 
praclice on the dead body. And, even when the iiitrudiiction can be 
effected with tokrahie facilily, it is not unlikely that mch means will 
in the end be found quit? inadeqnate to remove the diGease. In all 
serious cases of obstruction [u the nasal duct, therefore, it is beUer at 
once to have n^courat^ to tho fiumv trc^atmont as fur fistula loehryiaalid ; 
to puncture the sac, and proceed with gradual dilatation by Hlylea. 

OMita'aiion and Alienee of the Nttsal DucL 

1. The nasal duct may liu obliserated bv dmiige of istruclare in 
(ho mombrano. Rojiloration hy perforation tuay he attempted, 9. It 
may be shut tjp entirely by change of fitruetnre in the hone. Then 
restoration in the orii^al h\ie is hopelebB ; and if anylUn^' remedial is 
attempted, il c.nn only he by perforating the ob unguis, and rendering 
the unnatural aperture permanent. 

A case is related by M. Reranl, of eongx?niial absentee of the nasal 
duct; from which there had rcBulted a congcnitiil fiatula, which con- 
tinned open and discharging at tlie ag*' of lweniy-nn<i. An artificial 
outlet was formed for the secretion, hy perforation of the os unguis.* 

Dai^oiites. 

Concretions aro Hometiuies found in the lachrjTual paseages ; 
mainly lodf^ed in the sac ; and cfmsifiling cliieSy of carbonate of lime, 
cemented hy concrete mucous and albominona matter. The foreign 
Kiihstance proihices spelling and lachn^nialion, and may ultimately 
cnuse fistula. Its presence iseafily detected by unmipulalion, and by 
the inirodnclion of a probe through one of the jmncfa. The remedy 
JE simple; incision and removal. Tht woniid may Ixr expected to 
heal kindly, and without any Gstulot^a tendency- In minor ca^eB, 
mere e^cpression, without wound^ may prove sufficient. 

AffectioTvi of the Lachrymal Glattd, 

Dacryadtnitis. — The lachrymal gland may be the seat of an iuflam- 
matory process, chronic or acnte ; htit either form of attack ik rare. 
The secretion is firat increascil, afterwards arrestml, anil then rei^toiRd 
in a perverted form. A painful fiwelling forms in the region of the 
organ ; the eyeball is displaced^ and inconvenienced in function and 
movements. The eyelids are {Edematous ; and the conjunctiva is apt 
to sympathise and tuke part in the morbid proccKS- In the acute 
form, the ^etom sufiora eercrely ; the pain growa intenac and ahoota 

* QHtinli And Forei^ Review, Ko. 2i, p- Ml. 




ENCAHTSm. 



sa 



ihroii^h tile head; and si]|^piiriitiou ma.y lake pWe. If tbc muttt-r 
be diijchjirgcd spoil taaeou^ly, a dstulous aperture ma^ reEaoiu. 

The treatment ib according lo general anlaphlogifitic princiiden ; 
when miLttcr forms, nn (iarly and free openiag ia to be made. 

Atrop/iif of tilt Lftc/iri/iiial Gland may lake place, but this is very 
rare; tlio uri^n uUimatcIv becooiirjg almost efTaced. Then cithf^r 
xeroma reeulte; or tin? conjunctival secretion ia aiigroented, lo atone 
for the glandular deficiency. 

Tumours of vmona kiitls may form in tlie substance uf the gland. 
It ia liable to einiplc liypertrophy ; ameDable to disculientii. Some- 
times it is the seat of cyslic fonnaiion ; remediable by Himple pane- 
tun:— or, if tijat fails, by eAcinioii. UarctJioiua mi\y attack tlie gla^nc). 
Then tliere is* obviously no liope but from early runKivuI. And, in 
extirpatioD of the eyeball on account of malignant disc^kse, it ia well 
always at Uie ^ame time to remove llie lachrymal glaml — ita ocpupa- 
liun now gime — whether involved or nut; lest, by its continued pre- 
sence, return and reproduction of the lunujiir filiould be favoured. 

EjicarttJas, 

By ihifi term ia tnoaat an enlargemeat of the carutioula lachryinaliB* 
The enlargement may be a aimple and somewhat acute engorgement 
*»f the pari, the result of aTi inflammatory 
pTocesa resident therein. This will readily 
give way fo ordinnry trealim.'nl — Bcarific;a- 
don, or leeching, fomeatalion, and sorbefn- 
cieots. 

A chronic spelling, of the nature uf 
bypertropby or Bimple tumour, may occur ; 
lesa ameDaUe to discussion, and often reeustful 
of it. tt slowly increases; proiluoing deformity by ita promiikcnce 
and bulk ; displacing alt^ ol^tmcting tbe puncta and lachryma) 
canalw, wh^'nco troublesome lachrymalion results ; preventing dne 
closure of tbe eyelids ; and favouring the occurrence of ophthalmia. If 
discutients fail, under such circumstances, excision is to be practised: 
care being taken to leave the puucta, caualicuU, and lachrymal sac 
uiihijured. 

Sometimoe tho eantncle Ib tbe seat of tumour of a malignant, or at 
leaat suspiciour; character. In RUeh a case discussion is hopeless ; aod 
palliaiivea of any kind are not employed, if excision be proclicable^ 
By early as well as free removal only, can immunity from return be 
hoped for. It is very rarely, however, that excision of this tciturej en 
any account, is required. 

Fig. 33. Enunthb. 




nB-aa- 




84 



SirfPLB CON-IUNCTlVma. 



IV. Affkctionb of the Eyeball, 



Opfilhalinia. 

In Bnoh a work a^ this, it Ls iioL to be expected that so wide a fiiib- 

jecL iLH ihe affi'titionfi of tbe eye- 
ball — so iniporiant, variiHl, and 
niiraeruiiB— sbonld be fully dis- 
ciAw*cU^ ill idl it^ duluils. The 
■ loading poiritfl oidj can be rtver- 
j tidion ; the student being rffeired 
: for furtber infijn nation to tL© 
.' i many excellent monograplis in 
I tbis department of ISurgery. 

Opklhalmlfi ib ibe ^'uiieral lemi, 
ill wbioh all ufftctionR <if tbe vye- 
ball of jin inflammalciry natTire 
are comiirehended ; and, accord- 
ing jis the snperfieinl or more 
deeply seated textures are vx-- 




Flg. 31. 



voWed, lUe oplitbalniiu !« said to be Exlenial or lut«rnul. 



Affections oft/te Conj\inctiv<L 

The inHiinnaatoty pr-x'esa, in all ils grades, is very frequently 
fiuind eatablishLKl in the c<nijnnctiva ; and tll^' ivITecuon varies materially, 
not only according to Ibe intensity of llae process it^ielf, but also 
according lo the cause wbjeli [iidmjed il, and ibu stule of \\w M'alem 
in which it bjiK uecurri-d. Diffi^rent VitriEtipH of the diwase may in 
cojisequence be enumeraled. The most iiroininent of tbeso are the 
Simple, Fandent^ and StrumoiiH. « * 



Simplt Conjunctivitis. ■ 

Tbe eye bpcnmefl tbc scat of pain, heat, and lachrymatiun ; tbere 
ia intolerance of bgbt, and eoiiKeqnent ahutting ol' the eyolids — more 
or less spasmodic ; fre(3iiently theru is a eensation as if aand ef other 
foreign tnalter were lodged in the part. On fieparAtirg- tbe eyelids, 
tlie membrane is Been to prOBcat an appearance of nnimrial vaflcnlarity ; 
not from formation of new vesselfl, but from enlargement tif thofte 
already there, Ii is important tn remember that ibeM? ve>*ela have a 
peculiar ebaraetcr, nberrby afft-etion of tliis metnbrane may be dis- 
tiuguislied from the afFectionB of more deeply seated parts. The 

Fi^. 24- DiLi^ram slifl^vin^^ the cliamcterii^lic rd.4cu!jirlt; nf DxLumol ami IntPnul 
opbthilmui. afCxiTinl; A, internal.— \V. Jones. 




SIMPLE OOJ^JUNCTiVlTrs. 



85 



I 




Fif, 3«. 



veweU are of cansiHeTahlo hiz^, they aet^m to advanr^ from tbi> peri)>hery 
of the globe, wheru (he membrane is re Reeled from off the palpebroe, 
uifi lortuoiis in their coarse, freely 
inusciilate wiLli each utbtT, and ter- 
minate gradnaUy at ihe tnargfn of the 
oointa ; they are also obdeived lo 
fi>IIi>ff the movements of the xofiu- 
bt!ino ; 6ometimeB they arc distinct and 
separate, because not v»ry numeroue ; 
Hometiin^ they tre numberless, con- 
slitnting uiie ma^s of nagry red; and 
lh<i redneaa ia ueudly uf a bri^'lit 
scarlet htie. Whereas^ in aclerotitis 
the vessels are small, Ktrftight, not 
affected by the movements of the 
eyeball, appear SrH neax the margin 
of the cornea, l>ecome paler towarda 
Iho jwriphery tti the globe, Ji* nyt iiu^actilate, plainly occiijpy u deeper 
plane, and caii^<2 a n^UncBe of a pi»k or [lurplibh hiit^ {^^n- -^^j- 

[ii what is Klrictly tinned Simple f^Lininncfivitis, ihe rango of tlie 
infininraatory' jirofesfl does not reach bi^^licr than active coni^estioii. 
Effufflon tfticea place copiously; partly beneath the conjunctiva, but 
chiefly es^mal in it. If the crisia of true intiammalion be approached, 
a leinporarv drying up of the discbai^e, with a;^gravaEion of all the 
symptoms, marka the nnto^anl ndvanco. 

The Kysrem w synf^iatheticaliy involverj ; bnf, in general, ita dia- 
order is neither pTominent nor severe. 

The disease may oct;iir per se ; or be but a part of a moro general 
iuflaramatory attack. Not iinfreqaenlly, if is merely a ^ymploni of 
emplive fever: as in iu<?asles and ^niall'po:^. 

The predispofiing- caiiflcu are numerous ; over-exi>rticm of the organ 
in many wnvR ; derangement ^ the general health ; n g-laring, aniiuy, 
or dusty seasoa. The exciting cnuseB are equally nnraerona ; espOBiire 
to cold, heiit, wind, or li^ht; the application of all chemical and 
iwchaniL'al irrilantfl, directly; and the indirect influence of irritant 
cauEcs, more ri'mutely. The triost ohatifiate forms of iJie diarase are 
to be expected, when ihu exciting cause ia by a direct irritant which 
remains in eonsTant opernlion ; as when a parHcle of sand, dust, or 

giaaa, lodges in the membrane, or whim it is couHtantly rubbed or 
fretted by at ray eyelashes. 

In the treatment, our first care is to remove the cause. Then anii- 
pblopistics are to be used; hut these need not be of the highest 
cloBfi. If the coUHo — as a fL>rcign suhetance lodged in the tnemhraiK!— 
Viave beon removed at once, nolhing may bo rei.|mred in adilitiou to rest 
of both body and part, low diet, abatracliim of light, and continnons 

Fig. :^. Kxtenwl ni)|ith4lmU; rjiUnliAl i-oiijunL-tiTittH. 





8(J WlMl'Lt; CONJUNCTmTl^- 

nppl icMtion of cold ovf r thp phnt evplids Ly tth'Ilur uf wetted Unt- The 
iriflamioatory process may bo entirt^Iy averted ; or^ if jnst legTin, it 
may very sj>etdJJy resolve. If Dot, then HihkI is to be nbntTflcted 
I'KJHUy, iLH^ transition mado gradually from cold cb^tlis lo warm fomen- 
latiofis. The Mnod may lie drawn from !lie icnifile, or by nipping at 
the iifljjo pf the neck j or by tbc aiipliralinn i>f leechts in ihe ncigb- 
bourliuffd of the eve itself. The IsiBt (netborl uiid lofa-lvty are generally 

preferred ; and cure should be taken that all (be animals fiLsteu near 
the inner angle only, immediately bencaUi tbc tendon of the orhicularis; 
for there less paio will be occasioneil^ more blood will be drawn, and 
leas risk both of ecchymasib and of erysipelas will be incurred, than 
when application ia careleBsIy and diffusely made aluiig the eyelids. 
The amount of local de|il<.'tion will of course vary according to the 
intensity and duration of the di^eiit^e, and the uge and constitution of 
ihe patient. 

The process niay miuply and et^adily resolve ; or may ])asa from 
the aajle to tiie chronic condition, and there tend to remain. It is to 
be Iwrne in mind, that in all vu.rfi.-s of this dfrec^titjn, not of a traumatic 
origin, und not oecnrringin a rohust and vigurona frame, the chroric 
fondilion, .a staJc differinir little from that of mere pasHve eoiigeslion, 
is very npt to be aseiinied at an early perioii — afler Ihe lapse of but a 
few Uaj-fl- Then, coiitinuance of antiphlopistics would but a;;gravate 
the morbid state. A change has to be made. Ir may be advisable to 
nHbtulben [he diptended vessels; and this will bt beat done, by scari- 
ficjition of the conjunctiva nn the lower lid> By foinenNition, the flow 
of bluod is encournpfed ; and kftcr this has cea.scd, gently stiinulating 
collyria arc employed, te restore lone to the vessels ; — snlntions of zinc, 
alnm, or of nitrate of silver, are the best; or a dibition cf vinnm 
opii begim very weak, and gnidnally increased in atrength. Also the 
ordinary stimulus of light is ag^aiii f^rmbially mimitled. lu tliose Ciisas 
in which amendment ia l^irdy or fluctrnLting, tt In well to adopt the 
aid of coutiter-irritation; which i^ best applied by blistering, liehind 
the ear, 

Consiitnlional treatment is not lo be neglected during any period of 
the case; first moderately antiphlogistic, then wlterative, and ultimately 
lonie. If the occurrL-ncK of Ihe iittack have heen connected with the 
drying up of any habitual or noraial discharge, retarn of thie should 
be Bong-hl fnr and Ketured. 

When <ine eye only is affected, it is well to remember the close 
sympathy which exists between the two orf^^ana. The unafTecled eye, 
therefore, slionld, daring tlie acule stage, be kept eipially quiet and 
bhaded from the light, and otherwise treated with prophylactic care- 
Confinement to a dark mom is not generally neccseary however ; and 
when the eftse if rhronio, free expoeure of ihe organ lo the o|w>n jur 
'nill often prove W'Mcficial. 

In the obfilinalely chronic cases^ a beneficial change may often be 



PURULENT CONJDUCTlVmS, 37 

oblamed hy the ap|j]icaliou of nitrate of eilrer in solution, or very 
ligtitlv In Riibslance, lo tUe inoer surfiuie of tlie hvrvr lid immediately 
alter tK^&rificfiliou. 

A common variety of siniple conjiinctivilia ia ttrmed the Catarrhal ; 
whose prominent cliaractemtics are — in adJition to thoee of the wiuple 
form — a profiia*? accretion of vitiated miioO'pnndenL fluid from ibe 
m^mbraae, oedema of tie cyulida, irritation of the tarsal margins, less 
intoleraucti of li*^lit, luore uiarkeJ remissioDH, and the presence of the 
iisuol indication}! of catarrh, 

PnruUnt Cunjunctirttts, 

Pnmlent ojihthaiinia secniH to h(! merijly an ag^avated form of 
ealarrlial conjunctivitis ; mnning its oonrat, Ijowever, much more 
ra[>idly ; and mainly Jibtin^iisheU from the latter, in iis mild fornij by 
the discharg:e being purulent iaMf?ad of muco-pnrLjJent. But when 
purnlt^iit ditfcharge occura in the Muiple forni, an aggravation of the 
ioHammatory process having bcicn uonn^How indacdT sncb a circnmrstanco 
18 111 l»e ra^nle<l aA ah Ac^cidetital tnl4>nsily in acute simple conjnncti- 
vitis, rather thim as an esample of true pundent ophthalmia. UaTially, 
inflainirution is from liie first intense, and suppuration is very speedily 
attained. The tirat symptoms arc pain and itching in the palpebral 
conjunctiva, and often there Is a Benaation as if foreign matter were 
lod^^cd thcro- Then the ordinary characters of conjiinctivitia appear, 
in an aggravated form. The pain ia not confined to the eye, but shoots 
thruntrh the head, and nut nufreqaenrly extends to the face also. The 
eyeball becomcB quickly covereil with mcsheH of enlarged conjunctival 
vessels; the memlirana itself is infiltrated and tumid ; a profuse pnm- 
ieni secreiinn is poured out; tlie pyeliiJs are awoUen, and ojtlematous, 
often to a great eslent; ordinarily, the eyeball ia conce&led by the 
lumid lids; on opening them forcibly, pnrtilent miilter escapaH in 
increased quanlity^ and eversiou ia apt to eiiaue — ihe engorged and red 
conjunctiva becoming es|)osed. 

Aa the diseajw advances, the cmijnnclival lining of the eyelids, more 
especially of the up[H!r, changes from the uuiform, vaEcular, and vil- 
luja ftppcarauce, to one of more irregidarily, as if graimlaling. Tlit 
eonjimctiva ig then said to be granular. This term, liowever, does nnt 

imply that the membrane beeomes actually studded with true granula- 
tions ; the fleshy elevations being mere enlargemenla of the natural 
papilhe. These continue to fumiah a pi-ofiise discharge \ and the 
friction of Ihem over the ocular conjanctiva doubtless maintains the 
general morbid conditiun. 

The ocular c^>njunctiva, i1 haa boen alroady baid, underj^a ehangt 
ofstnictnre- Exudation and extravasation take place bf.th inti^rsti- 
tially and beneath it. Semm, or fibrin^ if the Jiseaae be very acmte, 
is efi'nsed between it and the Hclerutic, causing it to bulge cuiiKiderably 





88 PUBU1.ENT CONJUNCTlVlTlfi, 

over the inarjnn of ibe cornea, and leaving thnt lexlnre in the relative 
poeilion of a ^lojiression or diniple. Tliiw Bliile is teniied Chemnsis ; the 
reault of tnie inlliimmatioTi in tbe conj^uicllva. When the affectiou is 
acute, and ilic ciiemLiBis great, tbe comea ifl in danger of slmgbiiig; 
partly from tbe mere inteneily of tbe inflammation, and partly bj- 
t!ie strjTigiilftting cffeot of ibe Burroundiag' swelling, cbecking tbe 
supply (jf blood to tbo cornea, and oauaing it to die fntn want of 
nutrition. 

Tlie fijstem Bympatbizes lo a great extent At firet iDHanimatorv 
fever is developed. Afterwards, the f:>nn of Cniistilntional IrrilalioTi 
ia cflcn assumed' Vision is in iuiiiLinent duDg^r, h^ change of sttruc- 
tnro in the comoa, and also by disorg-uuizotion of the entire globe ; for 
to the latter remilt this affection may advance, under circum^tJinceB of 
either neglect or severily. 

In Eg^'pt the disease prevails as an epidemic, and has done bo for 
ayes; of tbe moat virulent and intractable form ; very fatal to sight; 
originally induoeJ by eun and sand, prtipaguted, also, by direct con- 
tagion ; and in effocting rfprcduolion by the latlor rnofte, tbe flies Are 
said to be active agents — panaingfriim <me eye to another, tainted with 
the oonlagiouB matltr. In this cunnlry, it ia bapjiiiy both less freipient 
and leBB severe. It may follow injury ; and then tbe pnmlent discharge 
is to be looked on as the mere contieqtience of a high anioiiit of inflam- 
mation induced by a powerful exciting' cause. Want of cleanliness, 
luid of ventilation, &nd the ovcr-crowdmg of ioraates^as in schouls 
and barracks, and on lioard <if ^\\\t — predisjvjse to the production of 
tbia form of diseaee, under the influence of a comparatively aligbl 
exciting cause. Thus occat+ioncd, it m nndoubtedly contagious; the 
matter of one patient applied lo the sound conjunctiva of another being 
capable of inrludng a similar nffcction. And when many patienta 
happen to l»e crowded togclber, witbvnt dut Ldeanliness and vcntilatioii, 
there is good reuuin to believe that the infections character i^ aim 
acquired. 

Treatment, in energy and promplitnde^ requirea to be proportioned 
lo the rapidity and intensity cf the disease. It iH only by active and 
early, as well aa suitable n^eanurea, that we can hope to avert change 
of Blruciure and itu^Hiirmtiit of function. When tbij patient is robust 
and plethorin, nnd there i'^ inti*nsu sn[»rK-orhitftl pain, h4?adacb, che- 
uioeia, and a feelbg of teneion and (lirolrbing in the eye, blood la to be 
drawn not only from the pari, hut from the system ; with a full anti- 
phlogistic eftcet in view. The liowcls are to he well acted on. Kegi- 
men should be most sparing ; witli quiet, and Beclusion Inim all stimuli 
— light more especially. If not nlrongly coiAlru-indicatedj by cousliln- 
lional or otiier caimes^ caloincd and opiinii are to be freely lulministertd, 
to excite gentle ptyalisni ; for tbe inflaTimiation is intense, the texture 
delicate, and tbe fmielion iinfHirtarit. The eye is to be diligently 
fomenteil willi an an^wlyne fomentation. 



4 



t 




PURULENT COKJUVCTIVITIS. 



89 



■ 



If the case be not seen till the disease baa m&de pronjepg, ami lost 
muob of its acnle type, Ixjlb Widly and const ilutionaUy, snch severe 
measures are of conree nnwarnitttable. And a Hke reserviiLion will be 
required in the case uf ihe puny ad<>lcsccnt, perhaps scrofulons as well 
aa fdckly, who may happen nnfortiin^tely to becinne a victim. 

When ihe ft>onnd stftge has set in, we ceasa from crmstitiitional 
atitiplilojriEtics — tlioug-li still nuunlaintng the most guarded re^men ; 
the local, too, are proceeded wilh diffen?ntly. The fiwollen conjunc- 
tira JK to be freely s*7iLrifi;:d, in order lo empty its sangnineoiiB contents, 
and at the same liTue li) afford ample space and o]iportnnily for the 
interetilLjd iiuU fltibcfiiijnnclival eMidaUmi to cEtcaj^e, The palpt^'brnl 
conjunctiva is divided with a lancet tyr ficarifieator, in a hunz^jiilal 
direction ; the eyelitla being freely ev^rtwl for tbia purpose ; and separa- 
tion of ihe lids ought (o be mainuined for some time, so as tj fjLVoiir 
the escape of blooJ. The cliemoeed ocular conjunctiva is to he dividtrd 
also in a Loriaonial direction; otherwise, the eornea, already in a 
critical condition, will have ita eloiighmg accelerated aud made certain 
by interruption of the vafioular supply. Or, rather, (he tucidons are 
begnn a! the c.nrnea! margin, and made to ra<liati? ootwnrdT^ to the cir- 
cumference, as recommeuded by Mr, Tyrrell ; there bein;^ thus lees risk 
of cutlinif ncross the va:-cular supply of the c<>rnea, ihan in any other 
form of incieion. This incision of tlie chemosiB ifl doI alwava to l>e 
rcBsrved for tbu ttecond tlage ; hut is oflen highly expedient at an early 
period, when (he afFcctiuD is yet acute j in order to save, if ]Jospible, 
tbe threatort^d corM»a, a& well as to oblain a general resolutire i^fTect 
Upon the hfljimniatiim. Funientation ia lo he used for some boura 
after tbe scarification, so na to favour the flow of blood ; and then the 
nitrate of silver is advisable, Frobaldy the beat ivay of emplnjiug 
this remedy is to apjdy it, eiiher in substance, or iu soIuiioUT lo tbe 
eyelids ; on these it vxerta a dirtcl and powerful n^mtfliftl effect, o]ipoK- 
jn^ the congested and graindflr slate ; and from these it h gradnallv 
diffused over tbe ^lobe, with an effect more gentle but equally k*ne- 
ficial. The application is made daily, nr every second day, according 
to ci re u in stances- Thruugbout the whole Ireatment, it is essential that 
matter be ni>L allowed to accumulate beuf^alh (be liwcllen and shnt 
lida ; tliese are to t»t gently ojiened from time to time, aud the pus 
WAshtd away by warm water, or by aotiie gantly stringent fliiid — 

anodyne or stimulant, according to the Ma^e of tiic dispftse. For 
general use, (here is uulbin^ lietter than a weak solution of nitrate of 
rilver dropped into tbe eye once or twice a day. 

It ought to be tiorne in niiml, thn>ug;hout the whole period of 
(reatmeDl, that ibt dijicbarg« is of a contagious oaloro; find the patient, 
practitioner, and att^^ndants shonld guard accordingly against direct 
|irr>pHg'ation ^f the disease. 

If the uiorhid state still persist, und become m<»re and more chronir 
i[i character^ the nitrate of silver may lie well siiperseded by some 






90 PURULENT CONJUNCTTVITl}^ 

more purely BlimulaEin^ remedy ; as the feiilyljateB nf sine nnd copper, 
Or gome of liie preparalious of ujerciiry may bo emplo^dl ; in form 
t'llher of ointmeiit or uf solation. At this i^riod^ loo, coiuiler-irrila- 
tiou, by blistering behind the ears, or on the n^ipo ol Ihc neck, wtll 
tjot be witbout its xis/e. The slate of tho eyetem tliroxigbout Ihe whole 
course of the difejue, muat Ijo well conHldureii ; ofien a combTuation 
of tonica witb alleralivee will probably be reipiired. 

Wlien a fiwoUeti iljhI altered state of Ibe palpebral conjunctiva 
obKtiiialely reuiainfi, afler coni(»araUve diBappi^armi<:e of the other 
Bymptonis, this lingering one musl l>e allacked with loore energy. 
The sulpbule of tropper or nitrate of silver is applied ligbtly over tiie 
parts. Or ibu unlargod gnumlnlionB tatiy be nt onci^ removed^ eilhcr 
by kikife or hci^^Kirs. The Kurf^cc wbicb reinaina in then mafle llie 
g)ibject of ordinary treatmeTiL (If course, care mnst be tiiken thht the 
removal of lextnre l>e not excessive; olbtrmHe entropion Ih likely to 
enauG, 

Snch is the nainre of the cnlimirj' Purulent Ophthalmia, Two 
varietiefl of Ibe disease require a st-pjirale diougli brl^^f notice, 

Opi'thnlmUi Net'uaiorvni^ — Uy IhiF ienn is understood Pumlent 
ConjunctivitiB oecnrrin^ in llie rt'cenlly bom child. It may be in- 
duced by mere want of cleanliness^ ^y iaipmdcnt exposure of the deli- 
cate orpinfl nf sig-ht li> intense light, ur by ihe direet ajiplieation of 
oiher hliuinli, Bnt frequently it ones its ori<?;iii to fonljLniiii;ition of 
the con jnnetivpi by vaginal sfcrttii-iii — ibinii^' pjirUirilion, The discfiae 
profients ite onlinnry chftraetert ; and lliei* is mtn?b risk of ptrmiinenl 
loss of fiis-ht by pt'arly opanly nf the cornea. 

Childreo have been burjj willi op^upie eoniea, apparently the result 
of piinilent conjunct iviiis. It has been inferred, therefore, that this 
disease may occur in nlero. Such opacity, hofteverT miiy le the result 
of mere arrest in dc'vrhipment. 

Tbt! trcolmcnt ia f njiidi-d im nntiphli)gi!'tic principles ; ]in"portioned 
In the Rgf^ and ondilJon of tho BoflVrflr. Unt mueb dei^endw on an 
early commencement being mude. Then mild meafiiires suffice ; bleed- 
ing will seldom be required, either by leeches or by scarifications; and 
cmmter-irritation, alwi, will nirtdr be necessary. It is enough to em- 
ploy Bim])le ablnlion, frequi'nUy rqa-aled — ptrbajis every second hour; 
soon gently medicating ihn eollyrinm by meunB ■.■{ uliiiu, decoction of 
oak bark, '-•t other aslringcnt — the projiorlion of width is gradnnlly 
increased. A weak Bohilion of mtrale of silver dropped into the eye, 
once a day, is [»f much benefit. Oreat iitteuiion lo cleanlineBH is to be 
alwava maintained, Mnd the eyelids ^houlil be prevented from adhering 
torrelher, by applying a little red precipitate ointment lo their edges at 
■ right. AUt;ntiuzi i^ ut thi.' bjbujc Lime paid to the primte vin-, nnd 
girneral pyat«ii], 

Gonorrh<ral Ophihahnh. — The applieation of re^.-onl gonorrba'al 



■ 




STHUMOITfl COVJUN<n"lVTTlS- 



HI 



iTianer from ihe nrelhra \o the conjunctiva, pnxlnces llie most inlena- 
f.^rm of ptirulent conjanctivitls. Uiie eye. ordinarily h afT-cled; for 
it 15 seldom tbai liotli arc nt once inoculated ; und in tliifl n'spict tlieru 
is a diiTerence from the cominmi piirnlent conjuiicliviEis. In the latter 
also, the morbid procesa ueually oommencea in Ihe jial|>ebrftl conjnnn- 
tiva, resided thi?re c1iU'fl\% and extemU only Recoiidnrily I" tht o^iiUr 
pijriion *jf ihe membrmie. But in the goDorrhoaal fonn, the reverse is 
the case; the disease would weni, in moHt caKf-fl, fo commenfe in llie 
ocular conjunctiva, ftnd to exlend tli<:nc<! to the piiljicbml. luGmiiina- 
tioD i-H unusually intense; and tlie hazard to vision is great; for Uio 
comen, Mirixiundiid by a firm fiWhious tbeuicisia, is in u most perilous 
state, and poi unfreqnonlly p^riflhea by alonghing. Or the inflammation 
may pass deeply; and terminate in general disorganization of the 
globe. The treatment is in noway jtccnliar; only projuirlioned in 
a-ctivily to that of tl)e disorder, Ocneral bleeiiin^ ought seldom to he 
omitted at Uio onlRcl; and iliiji rnay be rcgardnl ae imparting a proper 
tone to the reut of the treatment. Stron<; solutions of nltniltt of silver 
are found to bo of much service, ko ftMm il£ the firfit aciilene^s of the 
inflammation has Iwcn subdued. The rest of the treatment it* similar 
to that nlrt-ady reconimeudvd in ordinary purulent conjimclivitis ; hut 
it should Ih} bume in miad thai this disease is more acute, and runs its 
course more rapidly than the other. 



Strumous ConjitncthitU. 

This affection of the membrani* — in addiliimto the ordinary tmts of 
the strumous cachesy — is chariictcrized chiefly by remarkable photo- 
phobia, or intolerance of light ; often ^vilh comparatively little pain, 
and vascularily — ihoiitrh soinetimeH the TiLsruUniy is considerable j by 
tendency of the enlarged vi^saelfl to tolled into faacicidi which strctth 
towLrda the corneal margin^ terminating there in pustuloa or phlyc- 
temilee; by esaccrbaliotis oceurring in the morning, while tliere are 
remiseions at nighl — tht opposite of what obtains in other ophlhahnia.\ 
Corneal change of stnicture^ as ulcer, is extremely ajjt to ensue. The 
afiecthin seldom occurs after puberty ; and prevails chiefly during 
chjldhoo<L At thjil age, l)je intolcranct; of li^lU, with spasmiKlIc 
cluenre of the eyelids and topions luchrrmation, is certainly the moat 
prominent symptom. The child ^' keeps its liimds pressed on tho fihnt 
tyelidK, and turns its face on the nurse's shoulder, or, if in bed, ou the 
[lilhiw, even in comprirntive diukncfis. ' In chrouifi cjisci, the edges of 
the lids are kept in this mannt'r in au almost inverted condition, and 
the eyeliibhes get under and are (here retained, augmenting the di^tretis/' 
The chetke are pcaldod by the diK(?hMrgo which almoat conhtantly weta 
them, and become covered with an angry eruption. The featnrea are 
contorted ; ^md a confirmed e^presshm of pain and discontent is fisAtimed. 
On attempting te open the lids, mucb suffering \b occasioned; the 





lafhryraation increases, the lids become more inverted, and the eyeball 
ia rolated ujiwaHs and outivanJa bo ils to conceal the comea. 

Tlie trcatinetit conEists in constitutional tnanag:eiiicn]f ignited to 
tfiis pardciil&r cachexy conjoined with an inflammatory process in an 
imtxjrlant part ; in alight local depletion by leeches ; in applying 
nitrate of silver to the integnnn-iit of the lirls, lightly, so Ba to blscten 
merely ; in the use of u wetik solution of this fiiihsi^ince a^ a ctillyrinm ; 
and in conn ter-iiri tut ion hy blistering; l^ehind the car. The last 
remedial means, however, Is Ii> be used with cantion ; ollierwifie it is 
apt to esrite trojibk-nome acrofiiliMis eilarpemcni of the eer\ical glande. 
SfjmcliiLies beiielii in obiaiiKKl by tli<' loc^d n^c of bciludunQH, bmearcd 
over the eyelirle, whii-li Geemfl tu act as u atHdiitive in such oa£OB, Or 
it may probably afford relief Uy lenipornrily jmralyKing the iris, and 
eo placing thai t'ontraftiie textnre in a tondilion of re])ose. In tiio 
early Etjij^ of the (liseniso, an emetic is ^ijenerally of nincli service. 
No medicine, however, secnis to net so beneficially a.s qniuine, which 
ofien Jinjilays a dmded intlueace in allaying tbe murhid sen^iyiily, 
rolioving the inloWanoo of liglil, iirid removin;;; the inflaniiHfltion, For 
bathing llio eyt'P, wnrm tt'aler \» n^iCil, simple or mi-'diiali'd with opinm. 
The child should have a Bolid and nutritions (tiel, and should not be 
confined to the hoiiBt^ unlc&a during cold and wet weather. 



Granvkrr Conjunctiva. 

The granular condilinn, de|feTidoiit on a hvperfrDphijid stale of the 
mucont* i^apillffi, nf the palpebral conjnnctivii, has been aln-ady noticed 

— ftjj conatimtlag im iniixjrlant integ7al 

part of puruknt conjunctivitiH. But 

a rtiniihir ehatige of structure may 

ufcur, quite indc|»cndenL]y of thia latter 

disease. It may be the n^fiiilt of 

chronic inflammatory process rcaident 

in llie pidpehnil membrane. At first, 

daubtlcti*, there is mere enlargement 

of the normal Binieiun; ; bni after a 

time, thir* ia nion? ur Itss alterej by 

conTiiiuanci.' of plastic depotif ; the 

Burfttce hetomin;,^ dense as well as 

prominent, rou^lj, irregular, anil some- 

•limcH fissured. The upper evelid is 

more prone to sutTer than tlic fuwer. 

It can be n^adily uuderstood how mich a strnclure, nl each move* 

tnent of tho lid, miiBt greatly fret the ucidnr cunjimciivu ; eausing an 

irrilAtinn there sufficient to bgbt up tlu' intlanunatory process, and 

more than Bijflieicnt to inaintJiin an affeeliou which has been already 

Fm- ^ iTrAimlur Conjunrtivii, 11if tyeljil everted. 




Fij-Efl, 




PTERYQIDM. 



93 



eauibUiihed. To remavc tlie alterfllion cf etnicture, therefore, 1ji?camcH 
a TDotil imporlanL thcrnjr^utic indication. In the firal inAtnocff scdrifi- 
i?3ifioD of the ey«'ir(J h Xn Jte eiiTployecI ; followe^l by tht? ftpplicntion of 
nitrate of Eilver, nseil either lightly in BubBlanct on the |mrt, or in 
sttoQ^ solution- If rhe nitrate prove unBatisf;iotory, oilier ustringenls 
nifty be employed inat^^. tVilb^ tliescT thu ultert'd pnrt is U^ hi 
icjnoTt-d; by knif<-* or cBiiatic. The niinitii of silver, or sulphate of 
copper, mfty be applied firmly to the snrfaoe, »o as to have a dt-struo- 
live tffect^ But in gi'nend, it iii bvlter tu remove at once, hy Itnifo or 
scissors, the erilarg'e<l irranules; ^rcat cftre, ns iisnaK being observed, 
lc«t by eioesfljve ablution enirojjioii be eslahlished on cicnlrizaliont 
The g'eneral healtli ought in nil rnseh to be jUiendeil to, ha the iliaeafis 
fre(iuenl3y occurs in lymphatic or stnirnoua individuals. Repose of the 
eye ought lo be enjoined, witli duo attention to Jict, exercifie, and 
oliiinge of air. 



tlie CO men 



Pifr^ffiiini. 

FUrygium denotes a vasctilar and tletiby thictenin^ of tho ocular 
ovnJLini-Hiva. The fortnation is of a triangular form ; tlio base resting 
on iho internal or ostcmal oantbikti, and Uic npox Klrfitchin-v toi^'^irde 
the cornea. Win-n iif mirfleralj? ^v/x*, itnd not ailx'anced fnrdier than 
the corneal margin, vision is not inlcrftTi^d with ; bnJ when it beyiins 
to encroach on the corneu, the affection then censes to bi- a mere de- 
formity or incnnvenlence ; sight iH in danger ; nnd reniediid mcfls^res 
are re(|uireJ. Sometimes the web is iliin and niembranona; cjualsting 
chiefly of varicose vessels held together by iinc areular liasiie. Soiuc- 
lim^^K the structnrt is dt'oae, firm, and fleshy ; KomotiniPS it ronlnins a 
large jiropijrtion of adifjoae substance. 

The term Pannus'iA applied only to ll 
is completely covered with red veswels, 
presenting Ihe ap[>earanee of a Jiiece nf 
red cloth, and very materially interfer- 
ing with vision. 

In the nnider cases of Plerypiitm, 
a cure may he attempted by Bcarilica- 
linn ami astringents; the BcaHlicftlinns 
being matle ncroas ihe dilated vessels, 
in the aclcrotic conjunctiva. In thoae 
cases in whieh the cornea is encroached 
upon* excision of the sclerotic portion \a 
U\ be hail recoiirseto, if the milder measnies fail — as they areliktly to do. 
The membrane ia eltvi-ited bj a line hook, and cnrefully removed by 
kniff! or sci>*w>ra. The corneal covering is then usnally found l<» 
diaappcar» When, in PannuS| the whole cornea ia covered, a cure ia 
Fig. 37' Pterygium^ dnable, 






u 



COttXEITlS. 



said to hivi* benn cffectpd by inoculation of the inorhiii iissna with the 
dischsTf^e of purulent ctinjiinclivilis ; the bfiaimnatory process which 
thence results having the eSect of breaking up the morbid tissue, and 
rendering it amenable to remoral by absorption* This, however, is a 
very dangerous mcwle of tiefttment; iho eye mny be loHt in cunse- 
qiience of the violent in£aimnatiun which is induct, and the patient's 
health may \to much injured by the severe meninreft wbidj may be 
requiwte to suklue that inflammation. Such procedure, therefore, is 
plainly inapplicuble, except to those eitrtme cases in which the ctirnea 
pre^Dts no souuil part., but h (completely and thickly covered ; and lu 
which, consequenllyT the condition of the eye can scarcely be made 
worse. 

Aphelions cf tht Cornea^ 

Comeitis. 

The inflammatory process, affecting the cornea, may be either an 
original affection, or merely aii extension from prevluusly existing 
oonjtinetivitifi. It may oiiginate either from injnry done directly to 
the iiart itself, or from an exciling cause applied to some other part of 
ibe surface of the eye. The conjunctival inveslraent only may be 
involved — and this is most likely to occur when the afFection is a mere 
eiten^Eon from coujunctlrilis ; or the disease may be mainly and origi- 
nally resident in the proper Bubstauce of the cornen. All forme of 
conjimetivjtis, A^hcn of any duration, are apt to implicnto tho cornea ; 
but the slruDious fortn more especially. 

A red aone of dilated vessels encircles the corneal margin, gene- 
rally at the upper i^art; and between tbo two there is no intervening 
clear space of white sclerotic, as in afTcctions of the dee]>er patls ot 
tbo eye. When tlie conjtinctival euvering Is involved, small hair-lilse 
vosboIb are Been ramifying on it, in greater or Icbe number, uODtinuoue 

;\ilh tbi*so constituting tho outer zone. 
Wlicn tJie proper flubslauce alone is 
nlTected, sut^b vascularity is, in Ibe 
first instAnce, not discernible, unlees 
by the aid of a magnifying glass. 
There is pain in the eye, Bod in the 
orbit generally; lachrynmlion and in - 
/ tolerance of light. By and by, the 
cornea loses its transparency, becoming 
Uirbid, and of a bluish white appear- 
ance. The various results of the in- 
flammatory procew may theo ensue — varying according to its intensity ; 
deposit c^r plnetic lymph, producing tliiotening and opacity; formation 
nf pus between the corneal layers, afterwanls absorbed, or making its 

Pl^.Sa Comeilia. 




ri|.» 




fX^RNElTIS. 



96 



I 



way either ertemally or into the anleni)r chflTulier ; clronic ulceration, 
rouitnencmg superficially, with more abriisiaa, In which ca&c ihe Burface 
of the comea is more or less rong^h, and bears some resemblaoce to a 
piece uf groitnd glass, bat which uppearance, on c1o8o int;pectioti, it 
fbuod to contn^t of a crowil of mioitte ulcere; or tht^re may be ». large 
nicer, originntirig in ih& giving way of a pustular formntion ; lastly, 
iltiitghiii^, either of the whole or of a port — seldom octiirting in the 
ca«e of simple comeitis alone, biit only when this is part of an exteimive 
and sevoTC uphchalmia. If a foreign body be kft iuihedili?d in lh« 
comea, it ia very evident that Inflainmation, Buppnralion, and ulceration 
must ensiic ; in obtdience tu llie gencrnl Law, wlitreby natural extni- 
BIOD uf foreign malLer is cS&4?ti!d in all livin;^ textures, 

III the Ireatmcnt, j^'enefEil deplelinn is not oftt^n neceasary ; locjd 
abfltraction of hlond, however, bj Iteches, k of much service, Countef-* 
irritanLB, by means of blisters behind the e;irs, aro of nae. Purgatives, 
antimony, and mercury, are llie niofit approprinlc remt-Liies for arresting 
the progresB and removing the effecla uf ihe disease, Bui of ihuhc, 
mercury seoms to act looro WnefidjOly tban any otbt^n When % 
debilitated condition of the s^'stt^m cauR^ri pmtraction of the maliidyf 
the eye contimiinjr irritable and intolerant of li^ht, fpiinine and an 
improved diet will be reipiired. At 6rsl, llie local appli<:alionM Kbonld 
coDBist of opiate fomentationB ; but as the fliscaBO Wcomcamore clircitiic, 
weak HtJiDulanib, as v[[ium o[tii, or a r^olutiou of nitrate uf btlvi^r (four 
gTBJna to the ounce) are to be employed. 

Stnrmoiis Ciymeitia is of very frecpient oecurri'uew in thfi ycjung ; it 
is more chronic than the siniplc furm; and usually mainly reeident in 
the conjunctival coverin°;. Tlie va-sculariLy is Ws, und more diffuse; 
and the zonular arrang<^menl at the corneal marg^in iw lesa dislinclly 
marked. Opacity is the ordinary result; and pusiuk-s, ending in 
troublesome ulcers, arc nut unemumon. The treatment i-*^ Niic;h va ia 
calculnl^d to subdue chninie conjunctiviil^ ; with &n especial rtft^r^noe 
to the depraved slate of system. Mild mercurials should be given 
to check the depofcilion of opnqne matter in the cornea ; ai*d, combined 
with thcfie, quiDine is useful to im[)rove the general slate of the 
system. In general, the afftTiinn proves of rather aii intractable nature. 

AqtW'CaptuIitU. — Tbia len» {lemtU's the iuflaraiualyrj protefta 
ravdent m the i^rouH membrane of th^- aqu«ons humour, including the 
intenial layer of the cornea. It may occur p^rr mc ; or it may Eona au 
integral part of the preceding affection. It is charact^^rised by *'a 
pale, deeplj'Beated opacity, which it* uneqnally distribuLcdf imparting 
lo the cornea a mottled appearance ; and by a turbid or clondy sUte 
of the aqueouA humour.'' Sometimes lympb id exuded, Aotl coats the 
membraoe. This diveote i& very apt lu nin on lo in flam mat ioa of the 
iris. The trealiuent ia aa for comeitis, er iritis. 





96 



ULCER or THE CORKEA. 



AitKtsa of the Comra. 

Hatter, ae we have neen, may form between the lajera of ihe 
comea; a rentilt of comeilia. If it collect at the lowet part, the 
acciimuktion ufiuallj' assiiniea a croFcentic form ; re*^eral)ling ihe while 
semilunar in^irk at ilie root of ihe nail ; fiml hcni'e siich nn appearance 
is leniieil Onyjr. Dul it may Ije depifsiltU elftcwbere; in tbu form of 
dota or ]x>int9, wbich mny ciiher rcmnin popamto, or may unite with 
each other by increaRe anil extensk'Ti. The fluid Keems to be ptirnl*?iit- 
It may, tiowever, be a less advinceil iiifljimmalor}' exudjition, 

Anlipblogihtics will i^lainly Im? the most likely means whereby the 
secretion may lie arresteil^ ;infi ils clisrtppearanee by absorption favoured. 
And in order to effecl ibet-e two lEidioaliona rapidly, in time (i> savB 
Btmoturo and fiinctioji, the systcmio inHupnce of mercury is highly 
available — obta-ini^d aa Rrmn aflpr Iocb.1 bb^i id-letting a.i poR.viblA. 
Failing absorjilion, one of three evenls may oecfir. The fimall collee- 
tioti may sponianeonsly dii^ebiir^e ilself internally, into the iiqiieoiia 
bnmonrj forming nn liypopion; or it miiy ass^ime llie pnsiTilar form, 
anil escape externally^ svben an nicer will lie ilie result; or an ariifl* 
cial opening mny Ikt made for ita external cvflcnation. In ihe grcnicr 
nunilipr of cn^cH^ the arriflciiil opptiing v^ wlilibeld. in ibe liope that 
diBappearance by nbsorplion niHV li^ke jilaee; iuid tlie frequency with 
wliich this rewilt doefci octrur. would Iiud to a *iUKpieion tbnt the flnid 
JB not tndy pnnilent. If, however, the fluid be of conftiderabJc quan- 
tity, causing len^inn in the part, nifd paiiifid Mniploms of an aggra- 
VBlcd character^ the apex of Ihe abaciea may sometimcB be tonched 
beneficially, ^vilb a fine pint of the nitrate uf tilver. A small filoiigh 
is thrown oD", the matter is discharged, and an nicer remains, which 
heals readily. The imly a]ip]ication to ihe eye sbonld be ojiiiite fonien- 
tathmfl. 

Ukcr of the CornetK 

UlcerH arc often the reenlt of corneUis, TUoir origin niuybo from 
without, when die conjnnctival covering ef the mmefl ia chiefly affef^ted, 
and then ibe commencement ih with Biiperliciid abrasion, sometimes 
extensive ; or a piisliile fonnB, olevjUiug the tonjnnctivd Inyer — and 
on the giving way of ibis, nlteralion folloWB, still BiiperfieiHl. Or the 
origin may be frtim within ; mjvit<'r culkcis between the true corneal 
Jaji'rs, and is diachargXid csiernully, leaving an uloernted aperture; or 
foreign mailer liae lodged in the cornea, and h extrudt'd liy eiipfura- 
tinn and nlceration. In either of the% latter eascf, the ulcer is deeply 
Heated, and Feril^uB. 

The ulcer here^ as elsewhere, preHents different cbaracterp, under 
different L'irenniHlftncea, Someiimes it is acute ; the inflnminatiun is 
slill in progrcHs, loss of siibslanfe is advancing^ and there la *" 
at repntr^ In this state, the ulcer looks oa if a portio" 



tLCKH OF THE CORNEA. 



97 



mbsUDCe liatl Wen dug out meclianically ; the edges are nbmpt, or 
they mav bt- thickened uuJ &\volku. Very frequently, ii distinot plexus 
of vessels is found k'uding to the uker. The pain, lachrj'mation, and 
photophobia aie most distrt's^ing. Or the ulcer degeiieralea into the 
initablii form; the loss of Biibaljinoe gru'^mg neither larger nor less i 
the mwrgiiis and riiHWoo showing aa angry and vahcnlar ftppe:ir:tncej 
often as if ci>vert<l with a layer of welled cbalk ; and ihc eymptoms 
all imderguiEig intense Hggrrtvali(.Mi. Or the sore may he of a healthy 
And healing' difljiosition. Then the edi^eR are l*sa abrupt, aiid its if 
bevelled off; tbe chasm is dLminishing ; awhile Ijaziness surrounds 
Uie margme, and mvenia the siixfacjc^T denulii^g thij deposit of plaalic 
exudntion ; anii the unpleasant BymptocaH are all very much diminished. 
Or the ulcer may stop Hliort in the progress tcwards cicatrizulion, and 
assame the iuclolent cbarncier ; becoming stationarVf and causing com- 
paralively little inconvenieTice. This last phase, however, is certainly 
not Ibe one of moat frequent occurrence. 

Ill the carte of Iho acule idcer, it in obviuiia ihat the only euitable 
treatmsut \s ^ntiphlo^slic ; with mercury given if necessary in smiill 
quanLily in order to change the perverted eoiidition of the cajjillarieB ; 
ami this is to be continncrlT along with an especial re^^ard ta the 
general healtli, until tlie intiainmalioii ih milidnedi and symptoms of 
repair siicceed those uf destruction of lexlure, Tla-n, in the healing- 
bore, we must coiileuL onraelves willi Wittcliing tie naliual [iro^ttis of 
onre, ajid earerally giiurdin^ against reaccoEsiun of infijimrualiuLi f by 
delusion of light anl other stimuli, by regulatinn of dit't, and by the 
use of tepid sootliing applications. In the irritable sore nothing Is mi 
uBefiil as the niinite of silver; applied either liglitly in substance li> 
the ulcer, or in solution by means of a hair jjeneil. It acts probably 
in two ways; by its esdijuotic [mwer JeaLrojing tlit- w:niieia txlru- 
mitios of iIjo nor^otis tiesn« ; by its congnlating |M3uer rorming a prii- 
tectiiig film for the raw Burfaee- The application is repeated every 
sefxuid or third day, until the irritability cease; or the interval is 
Bborlened or increased as circumslancea may seem to require, WJjeri 
either the irritable or inliamei^i condition threatens to prove obstinate, 
great b^neiit often is derived from coniiter-ivriLiitioii by blistering 
behind the ears. For tlie indolunt sure, thu varioud BtiimdHat eol- 
lyria are snitable. When the stnimons habit is htrongly deehired — as 
it too uflen is — little permanent good will be done by any Wal 
management, unless constitutional treatment he at the sume time duly 
employed. 

As a ^neral rnle, the preparationfi of Iciid should never be em- 
ployed an ciillyria, in the cuae of uk'er of the coruen. An ioRolublo 
chloride of l^^ni will l)o fonnetl ; and this, b'^cijming entangled \a tlie 
cicatrix, will reniler it more irremediably op-iquo thwi it otberwwe 
uld have been. The suatained use of nitrate of silver, nlso, should 

'mdacted with caution; lest an olive-coloured stain ensue. 

EI 





MYOCEPHALOK. 



When the nlrpr is ilccp, acute, and [rituate near the centre of the 
corneiL, there is great rink of p^rfomtiun of tlie inner layer, escape of 
the aqueous humour, and protrusion of the free mar^n of the iris, to 
a g^eftler or less extent. To obviate this last accideul, as much as 
poiMiLIe, belladoiiLtt ifi employed to uiaiiiliiin a dihiled stale of the 
pupil 'j BO that the margin of the iris may ho rotrAcit^d, out of horni's 
way. If, howevLT, tlie wte of nicer he towards the circ urn fere ace, the 
use of l}ellml<mna wonid i>rohahly Uu prejudicial. 

Previouely to comiileUoJi of the (juriorated iiperture, the membrane 
of the atjuei>U8 humour soiuetitnea protrudes, iu the form of a small 
transparent veaiolo ; lliuj condition is termed Ifernia 'tf the Cornea^ It 
ought to be louthud oecnsioimlly with n tiuluiion of tnlrate of silver, 
and tin- iris nh^iiihi bfl kept fully diluted by bplladonua to prevent its 
bein^ prdapfjed, in the event of complete perforation taking place. 

Homeliuiefl the [>erforating uiour heals ouly in part ; eontractB, hut 
dotifl hut chise ; beeotDing a tiKluloua ajierlure, througli wliich Ihe 
aqueous humour continues to eKcajie. Tliis is remedied hy the ecca- 
monikl applicatiijn of nilTfttc of Hilver, finely puintrd, to tho part.; and 
hy a tonic syiitom uf treatment conBtituliuoally- 

The IriH, protniding; through the perforated i:ornea, foruit a blaek 
luiiiuur, usually of no great size; bearing a sliglil resemblance to the 
he^d of a rty ; and therefore termed Mt/ucfpfialon. 
Soroetimea the iris dues not proLnide, but simply 
rebfa upon the aptrtuci^, and clo.sea it up ; and in 
this ahnonoal position it may become adbtrent. 
In fiilher case, the pupil will he deformed ; and 
vision may he seriously impairerl. The indica- 
liona of cm*e are, to rcfitore the iria to its normal 
posititJii, and to ha£ten cicatrization of the aper- 
ftfr**- tore* III rcceat casesj the protrusion, when 

Nli^ht, nay be overcome hy plaeing* the patient on his haok, and 
applying belladonna ; and antiphhtgistica are to be employed, to 
avert or moderate the inflammatory process which ih expected to 
enaue. When, however^ protrnsion is considerable, the aperture being 
capaciouH, immediate replacement is not deairahle ; temporary and 
partial protnitiion heing Lhe Ealotury meaoa whereby Nature prevents 
cumpl*3to escape of the aqueous humoar, anj eoufiequtnt eollapse of the 
eyo- Under aiich circumatancea, wo coutenl ourselveB with rest, ex- 
eluaiou of light, supine picture, use of belladonna, and oa^asional 
upplit^ation of the nitrate of silver ; thus promoting healing of the aore, 
roukoving irritubiliiy of the texture invidved, and favouring gradual 
replocouieut of the iris. In ca&ea in whi^h the diBphiced portion of the 
iriK biiH (-■itnirat'led penuanent adhesions with the cornoa, riipUcemeiit 
tTaiLhot hi eileoli'd ; removal of the protruded part is h*wl recount to, 
oithur by etilliiig inalnjmenls, er by caustic ; and then doatriKatiun of 
thi* ri'muiniiig H')ro ia attended to. 

Fig- 79 Myocepiu!^ 





OPACITIES OF THE COllNEA. 



?>9 



Opacities of the Cornea. 

Nebula ia the thin clotidy opacity which foUowM inflammatory 
afr<!Clioo of the conjunctiva] covering of the comca< II arises from 
fligbt stniclural cban^ remaining in Ujat tissue ; and ia the I'onu 
of upiwrity uiouL likel/ to be remuved, wj as io leave Ibe part ultogctlier 
of its licnitliy cburacter. The indicntious of trcatuioiit arc- — to ubtnin 
final extinction of any mflammalorj excitement wluc^li rn^y remain; 
and, afti^rwards, to favour dL.s&ppcaruuce of the btrucLural cliange by 
abBurplion. The former iQdi{;ation is fulfilk'ij by (be iisna.! means; 
Ibe Utter, by the ^nmrded use of varioiifi stimulant applications. The 
mtraio uf Bilvtr, biiljjhalc uf zinc, cr ulhtr MJlwUnctf>» inaj be applied 
in flolution ; or fine powdtTS — em ouloruoli oxide of ainc, alnm, ic. — 
may be blown on tb*? part thnrngb a qnill; grei^t care bein^ always 
takes, that this part of the Lreutmcnt ia not overdonei Juid inflam- 
matory reaccession, with probable extcEjsJon of the opacit/i consequently 
re-eHtabLiabed. In the more oL)Slina1e cases, iodine is said 1o be ad- 
vLwble, boiU exiemally aiid iulcrnully. And of late, the hK^al use of 
li^dn>cyfim<! acid bas been fonnd of considi^rnhle avaiL The statD of 
the eyelids should, in al! cnpes, be carefully attended to; for, not 
uafrtqiiently, a granular condition of the palit'bral conjunctiva is the 
cause of the opacity's continuance^ if net cf its first formation. The 
curative procera is necessarily ^adiial; and patient perseverance in 
the use of remedial means Is cunsequen ily rcquirerl, 

Aituffo denottfl ihe nmrc deeply aoaied opacity^ which rcsultB from 
plastie oxndatiun betwt^en the layera of the cornea, It^ tuOr is nmenable 
to ataorption ; but not so favourably as the conjuiiclival depoat. The 
treatment is condiicttd oc the same principles; but i\ith a certainty of 
longer perseverance being required, and with a less sanguine expecta- 
tion of an altogether snccessful issue. If the cbauged part be seen 
travtrBcd l>y blood- vcasela, the prospect of complete cure mity be 
regarded as enpecially unpromiaijtg- 

Leucoma is the den^^e, pearly npacily, which results from cicatri- 
zatioQ of a granulating woTind or ulcer of the coniea ; it is, in short, a 
corneal ciciitrix — thick, opaque^ and little amenable lo change. Some- 
times there ia a black point in tbc oiberwise white opacity ; denoting 
entanglement, at that part, of a portion of the iria. Treatment, nitb 
the hope of diBcusfiion, is of liltle ur no avail. Remaining excitement 
is subdued, and then stimulants employed- But the laUer are not 
used with the hope of altering the cicatrix itself; but only in order to 
dissipale the nebulous or the albuginons b!tlO| with nbiijh Ihe leucoioa 
is usually surromided. If the opacity be central and small, vision will 
be greatly improved by habitual dilatation of the pupil by mcana of 
belladonna ; if it be both centra.1 and large, the only hope of amend- 
ment is by the formatiifU of an artificial pupil. 

It has been proposed to dissect off opacities of the cornea; but 





UH> 



■TTAniYLOHA or TUB OJnSBA. 



Dbvim^ mteetm f.^t^ uevpr fitllow any micb pror^tire ; iroj^murh rh 
tli# IfRMof nilxrUntM!, riiiiHi;-<l by the 'tiwectioii, mu^ fieal in tlie onli- 
nar)' wty^ biiJ, M" biHlin^, murt iirwlucc at luast au equally opaqne 
mti\ cilmmivw d'^fltri*- El liw U-en propused, lu>wever, lo <iperftle in 
irtio ijIWM <>r cjuu-M ; willi ti rurjiiiifil und fuir pronpcct of uhimjite b^uefil. 
Thn iiyn^diy wliirlj fidlffWfl injury of iUc tomen by milpUuric acid would 
hwrn, iM'iwiPLJ'fiirLlly iil li^mt, !<» Hi> n c-Iromit^ul tntrnistAlinn on ihi- c^omea, 

r*tlHrr ihun u viljd *O.Hfiifi! nl" iiml in iIh HtnicUiK' ; snljihoproU-ic acid 
in Hjiiij u, \»^ ]'r*i(h\cv']t arid iidhort'ti i'» llic exk-rnttl l&yer of the ccmeii ; 
ftrid thin Mifiy ho w;r*jKjd awuy, irniut'diuMy iifter receipt of the injury, 
[ly flu* iM^*^ '>( \i ISiir knife, li'itvin^ lh(+ rest of the yiari clear flJid free.* 
Ill mlv(u.r*ii| yi'iirh, tu«l niKruilimth tivtii in xhe cm i^ra lively ytiiuig- 
ii'hih, Uii' ronnml ji(.'Ti[klii*ry |,r'''i'l""'V l>oooni(?fl npjuiiU', iLiid cif » pftey 

iiohiitr, 'l^fiit rhiiii^^' fuiM tic^vii hIhiwii by Mr. CanloTi t€ depend on 
fully ih^fcpMdTHtiini of Llin iiMhtH' ; with n HurmiHe lliJit it nuiy Komttimes 
priivo 1ft bi^ fui iin|Htrlnnt «\lrraul iinUculiun uf similar lesion in more 
vllttl puMn.]- Tlio aflK'liad is leniied Arcus senif/s ; in itself a 
iiL<iii' iUiforMki<v; <uii1 ii<>t mnrtiHlilr In TL-ini^rli^d tiT'iitmoLit. 



Hth|ihyhn*i(i iif Ihp i'omeii is ftu opuqiie pmjection of a part, or of 
llio whi>U< ikf ihiN tiK'iiihriuio. 

IViIihI Mujdiyhnnu i^ iiRimUy eiidialt'd hI the loT^er or Intt^rul pEirt 
of llio imiinni- TIh^ hiN in mlbvronl In ihi" wholf* bmer fiuriace of llie 
jimjci^lion, flijd fonsequeiitly the aiilonur cLaniLer 
Is niiii^h diinini-shcd in size ; ^'entndly the pnpil 
UfuM is morp or U*ss iuvoh-eJ, nnd vi:^ion rendered 
vvTv imi»('rft*ol. The affeotiim is caused by an 
nli'iT i»iJit*tratLn(i ibe i-oniea, aud nllofting the 
iri»i |<» Wo-^^nv pr*fclan»eiti thfvnpK the <*iitning. 
When A rimsidemble [lorlioti nf the iris hns 
p^t|^llded. il di.w» v<*i shrink ulien iht infljuD- 
uiuii^tii &ii}tsidi^5, h\i\ T\'njAiiis aibd fenn^ a pn>- 
jwtii^^t At Ibill |iiu1 of thr ci>rm'A, After a tioie tiii^ piposed pro- 
jVCliMt i*f the iris h tw^rrd by ui op*qtw fimi lis&uc. of the tLalorr 
f^ ctf^trix. xUr r<i^r« of ^liicb l«n«w iiiixitpont«d ai tLt- base with 
iW n^imt <\^mni. It W gt-tierallt- rh^ rouH^qoeDcc <J stmrnoos, 
v^UirlitOs t^r (>HniWtil Qi^itlMUniw. 

Ti>Ia1 (ta^yk-ittui » forawd exactly xa ibe nine way; it diflen 
ottl^ in d*Vnv- Wbc«k» 9s B olt«fl Ibe cue is ponilctti ^iphtK^ifi*, 
d» wliUe (T |:TT«CrT |«rl i;i( Lbe cvnie* b ddtm^edf die icv £dl» far- 
««rdt» te |taf«l ck«r#. «>d tW ^ wioi* fci iM O M, ■rrBiimUripfl in A« 

* tMM^2A^l«l4^33ff. 




ly »ft 



fiTAniVLOMA OF TDB aUtNltfl, 



101 



c 



piWtftrifkr ebfttnlier, keeps the irin diatendefl im l.ho form nf & tiimoiir in 
the front uf ihe eye. The surface of tl;is lumuur, as in ihe partial 
et^hjloma, becontea gTi-ulually covered vith s, Qiia opikqite cicalrijc* 
like tissde of more or less tbickneiK ; and a toul staphyloma rcaiillH. 
This pscudo-corata or staiihyloma has the form and appcar:Lnce of a 
smiUl globe stuck on iho frijut of the eye, with si>meliiuoa a nny of the 
proper cont&t »4iirrounrling its base. It is often bo large as to prujeoC 
confflcleral>ly from hetireeri the eyelids, and prevent them from closiag. 

^Vhen the Btaphylonia in large^ the iris, being nnalile to expand 
to the same extent a5 the pHeiido- cornea, is torn and separated from 
the clioroid ; and when the ulapliyloma has been removed, the iris is 
foimd in coaiact Avith itfl iKifittricr snrfAce, brokeu tip arid in buredsi 
Thifi do^R not ijceur in a small or partial Htaphyloma. Viaiou in totiil 
Htaphyluma is completely de^Eroyed. 

For the treatment of a auaU partial staphyloma, tlie less that u 
done the better ; eseept to guard a^ui ust any tendeiicj lo iiAflammaiion. 
If It be largv and implicate the pupil, the projection may he diminiBhedf 
by touching it froux Ume to time uilli fiomc onuntic — an thu cauatic 
polaert — in order ta produce coodciiBatioii and eon traction - whicli it 
docs by exeiling a slow inflammatory procew. 

In the total sUpiiyloiua, relief is sometimes obtained hy ptmctnring' 
it from time to time with a large cataract needle, and allowing the 
aqaeous humour to escape ; wlien the projection collapser^ As the 
•queouB liuuiour, however, becomes alun.>&t invariably reproduced iu 
the eflnie or even greater quanlity ; and as thi- fiUipliyltJiiia is a great 
deformity, besides keeping up a constant state of irriUiLioD wliich la 
apt to estenrl to the other eye, its removal i^honld be recommended, so 
that an artilicial eye may be vom. In removini^ a HlBphylonia, the 
eyelids being projwrly fixed, and a hook passed lhroui;b the projeclion 
in unitir to cc^miuunU thi; gli^be, the ba^e uf tlii; tiiuioYir la traticiLxed 
with a cataract knife from its tempord to the nasid side, a lltilfl b«low 
its tranBverBe diameter; the knife in then pushed on, and a flap is formed 
as it cuts itself out. This fiap is seized with a pair of btaked forceps, 
and that part of the base of the staphyloma wliich remains uncut is 
divided with curved Bcissore, and the whole removed. The lens and 
BQDie of the vitreiniB hiiiutiur ofien ei^ca|je ; hut gem^rallj huflicient 
remains to form a good Btnmp for an ariiflcial eyv. Afler the opera- 
tion, a pledget of lint, soaked in cold water, should be kept applied 
upon the eyelidH, as a preventive of mflammation. !f severe reaction 
supervene, it is to he treated by active an tiph logistics. When bleeding 
fohi»Wrt the o[«rati(>n, it ia cbecketl by cold wet compresses, or by ice 
applied over Ihe eye.** 

" Vide Wluirluii Joutja' Miinml, ]i. I'^ el i^q. 





102 



OVES-DlSTENTinN UF THE COBflEA- 



Conical Comta~ 

Sometimes the cornea, " reiaining its trauBparency, gradnally B*- 
siimes a coniciil or p^TJimi^al form ; and when \'iewcd from certain 
positinns, reflects ihc light so strongly as to exhibit a peculiarly bril- 
liftut and sparkling appearance, characleristic tif the disease. It gene- 
rally affectB Ijoth eyeH^ though not in an etjiuLl degree; fcae been 
observed at all perioda of life, but more commonly iiboiil the age of 
paberty; and m fcaid to be most prevaknt among females/'* On the 
whole, it is a rare affection; and fortunately it is bo, being but little 
capable of amendment. If tlie apex protrude from between the lida, 

it is liable to become opaque. 
Or ulceraticm may take place; 
and then Btaphyloma is not mi- 
litely to BUpervene. 

In the clear conical comea, 
palliation may be obtained by 
adapting concave spectacles pro- 
vided with it small ceiilfal IniDH- 
pnrf^ncy. Lately, it bos been 
fiaid, that amendment, if not 
y\S^S'^. cnre, has followed perseverance 

in the nse of pnrgaiivea and emetics ;-[■ but how tlie beneficial reaalt 
is BO obtained, it is nut easy to understand or say. When the apex is 
opacpie, tempyrary anitlioratum of Highl may be secured, ly traiiH- 
ferring iho pupil to a puiiit uf the cireuoifurenao which is oh yet clear- 




OucT'distention oftht Comtit. 

Simple over- il intention of the comea, by an unwonted accnmala- 
lion of llie aqueous linmoiir, produces both dimness and pr<^mineneG. 
Xf ihia ijtate be the cuncomilaut of an cxtstinfj; iiiflnmmiitory proceea 
pervading the eye, os cumpitiJi, by subjiignlion i^'i iLis Hie coniea will 
sometimes be restored. If, on the other hand, the morbid state is not 
so connected, but ofa passive ami indolent nature, an tiph logistics \*\\\ 
do no good, aTiil are likely to do hann. From the internal use of 
the iodide of ivorasHinm, ur — fjiiUng this — from a c;iuiiously given 
jdtctnlive course of mu'ciiry, ninrc benefit is to be cxjicclL'd ; & dimi- 
uiition being thus made iu (he; nquoous hnmonr, on ndntse plethora \\\t: 
over-difilejilion depends. Rei>eated evw;uatiou of the ai^ueonfi bumour, 
by means ofa needle, ia often of service. 



• Lmri.T^ p. 1S8. 
f Juhlij] Joanial of Untical ^^Umhk, Juiuar}- Idftl, )i< ^T- 



«QLEBorms. 



103 



AJectwm of the Scltrotk CoaL 

Thb may occor a« part of a gtaeral inflammat'^Ty process, hov- 
ervrcxcit^fU Not nnfrcqnciii tl y* it exi^te per f, and ibcn oltnoal uni- 
formly ifi of rheuEOAtic ori^n ; expoMiire la oold, prfibablj, baviug 
provvd the exctttn^ taiise. It Is most frequent in ihe lulull, and about 
the mi<ldle periinl of life, and is often limited to one eye. Pain in 
complained of, of a dull, acbing kind ; increased by pressure, and by 
muvemenC of the globe; partly resident m the eye, htit mainJy iu tbe 
fon-faead and teinjile ; and marhtd exacerbation orcitrs at night. At tb^ 
ecmnienMtDenl rif the disease, the eye fepis hot nnd dry ; but tbii state 
is soon sncceeded by azk int^reased setretion of tears. There is, gene- 
rally, however, little lachrymation or inli>lerarice f»f light. The 
DUDute sclr^rotic vessels are seen enlarged^ radiatiug in straight lines, 
to form a vascular pJexus or zone of a pink huCi anjund the circum- 
(ercnce (»f the cornea (Fig. 23) ; and a narrow while line often eiicirclofl 
the ftjnitfL, between that membrane nnd the pink ^on^. Not luifre- 
quently, the pupil ir^ contmcted, and iTicft[kable of i[K wonted activity 
of motion ; tliU denotes that the iris hjis parllcijiatod iu t)ie morbid 
stale. The conjunctiva, too, fr^inently Bympuihixes more or less; 
and by ita large, florid, lorlnous vessels, the Bclerotic charaetef* may 
be in part ubBcnr«d. There are often rheumatic paina In uther (lartu 
of the body. 

Antiphlogistic trcntment is to be had reconrse to ; with an activity 
and continuance projmrtioned to the inlensiTy of the Hymptoma. The 
iris ought to be placed and kept under the influence of beliadimnrt. 
Mercurial and anodyne frictions should be made im the lemplc aud 
brow. And the tiyetem is io be put under tliu inducuce tif colchicum, 
iodide of p^fasHium, piaiacj salinea, or other remediL-a of anti-rbea- 
matic virtne. Cinchona urid soda, five grains of eiich, ^ven three 
times a dav, Bometimes cut Ibis diabase ^hovt when exhibited nt ita 
commeuL-ement. Counter-irritation, by blislflrs behind the eara, is 
alao of service. The only local application Hl^ould he le[pid fomen- 
tation, either Hiinfjle or medicated. Occa&ioiiully, iht affection is fmind 
aaoeiated with agnc ; aad then a eotuijinalion of quinine ivith ouIc>hk- 
cum h found uf much service. Should the iris become involved, the 
systemic influence of mercirry im to be unhesitatingly <!mployed, con- 
j<i[ned with the ordinary antipUogialic treatment proper for the cure 
of that affection. 

Staphyloma of the Schroitr. 

Tbis is mncb less frequent than Blaphyloma of the cornea. Gene- 
rally, it is the rcHUk of inflamnjatory affection of the ehort>id and 
change of structure so induced. The aclerotic becomes alteuuhted, and 





104 



CHOROIDITie, 



yielding; the churdd tioat, engorgeil, fihines through it; and irregular 
billing forwards takes place, con stitn ting several swolUngB of a bluish 
or leaden Ltie. Tlie external vessels are usually enlarged and lortiious. 
The bulging IB often to a great exleal; and consequently demands 
surgical interference, Wiien protnisiou Ukea place fn^tu between tbe 
lidflr then diminution by citber pTinctiire oi' incision is exi«<bent» as 
in the analogous affection of the coniea. Pnneluring the slaphy- 





louiatou!^ Gwelling fi'om time to time, and allowing the flind within to 
dniin off, Bometinies diaainishes the size of thi^ globe ; bul if this be not 
edectual, the hiLmuan^ ouglit to Xn; diticLar^ed ihrongh an ti^ciaJon in 
the cornea ] or tbo corneu itfielf may be altogether remoTcd^ and then 
the globe will collapse, and tbfi ^yo shrink to a small size. In the cFtrly 
stage, internal nee of the arKenical sohition seems to esert a beneficial 
influence in preventing or checking tbe bulginga of the sclerotic 



Affeciiojis of the Choroid Coat. 
ChtjroiditU. 

Choroiditis, though a frequent associate of iritis, sometimes evinces 
an independiiut existence, tt is generally confined to one eye ; and is 
most common in females of a slnimons tendency. The early symploroa 
ftre often gradual and insidious — becanse cbronic. Jtuflcm voliluntes, 
and an impaired *itJit^ of visir>n, iiniudly firat Jittract th© attention of the 
patient Those slowly increase, and terminate eventually in more or 
lesB complete amauro^s. 

Sclerotic vascularity is exhibited, in a fiunt and imperfect degree, 
at an early period of the disease ; it soon becomes aggravated, how- 
ever, and is generally more distinct at one or two points than at others. 
It is aticompAnied with a fueling of teuRion, and ileep-seateil pain; often 
severe, and extending to the Burrounding parts; the eyeball is tense 

rig. 32, Slaphylnnui uf tlie Srieroiic Coat; ««n in iirolile. 
Frg. 33, Tht BBinc dkeotv-, pe«c in fW^nt, Stapl^/onuf rin^tntomih 



HC$C£ VOUTASTES- 



105 



ftDii bard to ihe toiich, and by pressure ibe patD b a^ravat^; Eome- 
dm^s tbcre ia uitolenmce of Hgiit an«l pbtitt^^iGia. 

Tbe sclerotic now becomes uttenuatod bv absorption, assumiTig a 
dull blue or leaden bue from the <Urk choroid Ahiniug through it ; it 
aUo becoiincft irregnlarlT promiuent at certain puiata. The pupil is 
dilated, irre^lar, sn^l uf impaired mobility; it \r frpqnently dmgged 

and displaced in the direction of the pi-otnincnoea on the BcW'lic; 
vinoQ is more or less impaired^ Ulliiiiat4.'l)% t}ie whole glol>e heeomes 
enlarged, and staphyloma of the fcclemlic tnkes place — lhe thinned 
coat having bec-n piifihcd forwards., either by ihe svelhng caiit;c<l hy 
the enlarged and tortuous Tesbelb of the elioruid, or by the emdiition 
whjoh haa taken place &om them, B^ the inward pressure, to4i« tlis 
retina has becenie nn)re and more afFecled ; being pressed towards the 
centre of the e^e, where occadioually ji may be seen throngli the pupil, 
ia the form of a glistening or whitislj cord ; loss of vision is ul length 
ct^inplete. Geneiul internal ophthalmia is not unlikely to Kujiervene. 

TreatHicoC ahcmld timnitt in the abslniotioD of blooil both gen^^nilly 
and locally, but more j.^irlicukrly in tbe latter way j in the early Bluga 
of the disease, the eilreme vascnlariry of the chnni[d being more 
decidedly bfluenced hy abstraction of bio(>d tlian by almost any other 
renieily. In the sub-acnte form, blood m to he ftiliidriLwn with more 
caution ; aiid, in txtth forma of the dlseascj counter- irritul ion ia of good 
e*rviL?e. Turg^ativea albo nre useful. Mercury, givui tti as slightly to 
aiFect tbe eyslcm, seema in mauy fOBes tu arrest the iinlowarJ progresfi ; 
but when the malady is connected with a Simmons hahil. it re(|u:reft 
to be given with great caution, and ^'onerally should be combined with 
quinine, bon, iodine, and the hke. In siieh cases, iiiilritioiis diet, good 
air, and exercise ai'e also benelieial. The arseniatc of pot]i>4h givi.>n in 
Email doses, three liEoes a day, has oficii ]irnved lH»tieflcial in the 
advanced Etoge, when other rciucditia bavt^ faileJ. If ^taphylumri uf 
the sclerotic have occurred, puncture or incision may beconiB necessary, 
as already explained, 

Muscar Vvlttfrntea. 

Weak vision, rendered imperfect and iulermptetl by opaqne bodies 
Beeming to float before the eye, is generally (mderstiMid to depend on 
congcBlion of tbe choroid coaL The onlinary caupo in over-oTicrtinn 
of the organ, combine<l wilh aedentnry haiilH ; it ih alsi) often symplo- 
malic of d<;rangemeiit of tlic Htoiiiatih. The remedial treatment con- 
BiBts of moderate depletion from the neigh liour hood of the part, gentle 
purging, alteratives, careful diet, repose of the organ, hodily extrcise, 
and nltimately tonica. 





106 



lIUTIfi, 



AfftciionA o/tJie Irii. 

Iritis. 

Inflftmmalorj affection of the iris may be tlio rmult of injurv, or it 
nirtj bt r>f jdiopulhit; cjrigiii ; it may oci^ur priioaHIy^ itself I'onBtituting 
n diaease, or it may l>e but a part nf general flcep opblhulmiu; it in 
oflen connecltd with the fiypbililic, and mercurio-Hyjihilitic taints of 
hystem; and not iiiifreqiionl!}' It is of a rheumatic character. 

A pint or brick-reii vaRcnlar zone ift seen op the sclerotic, formed 
by the minute BiibUivtHions uf Lhv rtulerior ciliary arterieH, Tbis zoue 

is moRt distinct ne&r tho edgf of the 
eoniPfi, ami b**cotnPS grndnally shaded 
off Iowardn the circnm fere nee of the 
globe ; it ie more (»r !esa marked ac- 
i:ording to llie extent aud Ktage of Ww. 
iiiflammiitory jiroceti^, Tliere is at 
fi[-&t II distiiiel interajiaco of while, 
helweL'ii the VLLi^t^ilar 7ono nod the 
eorocdl mnrgin ; nllinkately thia wbit« 
line becomes ohscu red by iuvolvcinent 
of the coDJnnclival Teasels. The pnpil 
in (jonlracled, and mnch less movable thiin in lieiillh, under the ordi- 
nary ^tilHnhlo of light. Indeed, returning mtil»ilily uf thin part is one of 
ih© first and surest pign^ of iLmendrannt luivinij fiiSrly begiiu.* Tlie iris 
changes iLs hue; if of fl li^'ht colour nalnrally, il hecoraea green ifih ; if 
dark, it asanmeB a rcd'lish broivn apjicanince. It is also perceptibly 
Bwolleij, or thickened at its pupillary iiinr;pu ; wimetimes it is seen of 
increased vasenlnrily, and bulging forwanls in the anterior clinmber. 
Tiio eye is painful, int^iUTiiot iif light, and ihere \s> increased bichryuia- 
tlon ; pLiin in i'elt in tht' lm»w, lcni[df, iinU he^d, and nridergoes marked 
iioetumal exai^erbntion. Sight is gronlly impaifL-d. 

As the disease ftdvjinces, these syinptdins in<^rcase. The nqneiuis 
hunjonr becomes lurbid. Plastic deiiosiiiuu lakes place from ihe 
surface of the iris ; Bomelimes coating il witli a Ihin layer^ w^njetimea 
studiliiig il ^vllii uudolatL-d ji^ints ^ hoinctimcH dilTuhed in the antetiiu' 




Fiff.M. 



* GfYimf>1li» fnini Ihp (»T»^*rvniiim of iin0ii>9Hrii] Injri'tLMiii runrliiilm ihp irin (i> }m dfi 
cTK'tile tizimiv. Uc 'n^piPAi'a llitit euntrjiv'tiuTi uf lUe ywyW iLiirini> Ihu iiiftainmalitry prii- 
uaiB JcpcDcln ttiinply on i?D^pr|^i:mi;tiI ui thi^ radiating vean.'^ wliMi Are Irxud Ht ihe 
lircumfcrenrOf ouil Cn-c at cLu? jjupHUr^' iiiar>;ui \ uud i\iai rvliini iY tlit IpUmmI, in reei^lu' 
ti>in, iilloivi ihe iris 1o shriakt and Ihv pupil coDBequi^ody to expand. — Brit, and For. 
Rec.i No. 30, p. I^;^. 



Flg^ 31. Iritii 1 flliewljig Uie cliwci^rlittlc vucnlarlLy of til* ^iobr^ ilie trb <;1ui;haJ 
M ilh lymph, the pupil CMitrartfd Anil [rregular. 




iiuTm. 



107 



chaiober; *ttten And mo^t frequently silimte ut th^ free mar^ of the 

iris, lijiiigiiig pendulous in fringes fnjm (he circumferenoej forming n 
d«1ic4te network slretched across, or pcrhspB eMmpletoly Iflocbin^ up 
Uw already contrM.'ted pupil. And at tbia stage, if uot before, ibo 
offlitracted pupil is f>und to bo irregular in form, in cunboqiionce of 
adheuons iiavmg tiiken pitice between it and iht capsule of the 
leDS; an irregularity which becomes eepedally disUnetr when partial 
dilatatictti hna been effecUrd by belladuariA. Kxtrnva£:utioti of Miiod 
frmn the surface of the iris m&y oi^cnr ; nnall clots am HomctimcR to he 
Attn rcattng on it; ur the blood may gravitate to tbo lH>tloni of the 
anterior chamber, and acenmuJate tbere, otinstitnting the rotate termed 
Hr/potrma. Or effuRiun of pua into either chaTnl>er may take place. 
Ttie pus foriDB small abscfsses on the irii^ which soon ^ve way and 
ducbarge their cynteiits ; aud, grflvJtaiing to the b^ittom of ibe aiileridr 
fihambcTj it collecte there, constitutijig IJ_'/p"pion. SticIi ♦'vcnta indicate 
au intense mfhtmrnation : not only likely to prove Eiicwt prejudicial Eo 
the delicate texture involved, but nW almost certain to cxt^^nd to those 
oidjoining'. 

The reanit of fibrinous eiudat!f>n is denoted by various leruiH, 
according to its ifxti^Dl and Htte. Wbeu fibrin blocktf up the pupil 
pennaiLcntly, the enso ifl termed one of Faf^c Cataract. When ad- 
hesion has formed b<?tween th*( pOHterior surface of the iris and the 
capsule of the lens, it is termed Si/nrffiffi jfosterior. Whj?n the iris, 
bulging forwards, baa reached the post^riur layer of the coruea, nnd 
become adherent thereto, the term ^'fmrhia anterior in ajtplied. After 
a time, the vascularity ef the or^ani^cfl (ibriu can oiten be distinctly 
Men, when a strong light is thrown upon the part. 

Dnring aoHve ndvanre uf iht? ijiflnminsilory proceflft the eystem 
sympathises to a considerable extent; there i& oflen a marked form of 
iiiflammntory fever. 

Trtaimrnl. — Uur principal object is to arrest the pnigresa of the 
disease ni an early period, ere exudation or strut-HiiraL chunge has 
tidEen plact ; in order to avert all htuanl to the important purt, if 
pofiBiblp, Our renicdii^s ought to l»u i^Jirly, active, and pouerful. 
Blood fabordd be absitraclcd finely, hoth generally And locally. The 
eyu is kept dark or ^hiulcd^ and should be freijuently fouientedi The 
bi>we]a aie freely moved ; Jind then, aa r^ipidlj aa pissihle, the svfitem 
18 bronght nnder the full iuduence of mercury — iiiiUss there be Bome 
prC'Ciiflling and undcninble contraindication ; for in general it ia not 
till die moiilh is uffccled mnrcnrially, llmt ihe diMpnwi l)pgitiH (i> amend. 
If the sytftem, however, be strumous, and coDseipienlly intolerant of 
mercury; or when there is a known idiosyucrasy rendering all eshibi- 
don of the miuerul danj^eroiis by the iiiJiiclion of ercthisnius : — then a 
bTibstitiile rantt be anTght, likoly lo aid general iLuMpliloffistied in pre- 
venting exndalionj or ir causing its abBorplion. Tnrptnline Je often rt 
valuable remedy for this purpf^sa when given in fidl and continued 







IHlTtS. 

; • but il iH not atw-iyB to be trnjited to alone ; it seems to act belter 
vrhen a small ijiiantity of nierciirv has been previunsiy ^ven, wid then 
ita use fre<[uen[ly proves beiiuficiftl, not i>itly al the time, but alfin iu 
preventing- relitpnc of ibe disease. From the firal, bcllftdynnft is applied, 
Ro A^ tn t>p^M>»;i^ the leiidcnoy \<i cantmeLian in tbG pnpi}^ and efieot dila- 
tatiou if possible. Tbe Beiiii-fliiid extract is fioieared on tbe eyebrow 
and temple, or &n uqnooiia snliilion may be dropped between tbe eye- 
lids; but tbe former motbod nf application is n-^ually preferred, at 
leaAt In the firat instance. In tlu>fic cases in wbieh uereury is not 
contra- indicated, mercurial friction on tlir tempU and fore bead \a 
odvisftblOf U> niaiutam ibe coniitltiitianal eflbct wblch inl^mH.1 ^^^cliibition 
of tbe minend lias produced. In the more cbrtmic form of tbe diseaae, 
coantur- irritation may take tiic place of Lbe direct aniipLlogistJce. And, 
ultimately, wben (races of tbe aiTection still lingur, tbe internal adminis- 
tration Df tonics, esi^Pcially of quinine, proves beneficial by disaipttling 
the state uf piissivc co«gceli<jn wliii.b tiii-eat^ns to remain. 

Wben Hyi>opii:»n lias funned rapidlv, and wben tbe pnruTont act'U- 

miib^tioQ is considentble, it bas been projuised to make an ojiening at 
the lower part of the i^ornea^ bv tneans of a cataract knife, so as to 
eflFect evacuation. Tbis, however, is dangenuis ; it is better to tnist 
to the sorkefnc^ii^at powers of mercury, than to enojucter the risk of 
aggravated inilamination. 

Tbe extra ^'juated blond of Hypotpma shonld receive the some 
treatment. Aelive anliphbi^stics are bad rec^mrae to ; and these 
having toiil fuvonrnUly on ibe di5e^»5e, the extravasited blond may be 
ejcpected to disappear gradually by absoq^tion. Tbe oeenrrence of 
Hj1Ji>*ema, however, as indicalin* a high degree of inflammation, is 
Always of had oujen- 

The mlbeeioa^i, or SffnechifX^ are snperable in the recent state. By 
perseverance in the local use of belhhdonniL, Ihc impcrfeetly organized 
fibrin is extended or torn, and the iris recovers its nonnal play. At 
the fiame time, absorption t^f the Jepusit ia to be tavoured, by moderate 
coutinuauce u( the mercurial triction. 



Sifphiiitic Iritis is a frequent variety of the affection, occurring as 
part of tbe secondary train of venereal sjmptoma. Its characteristics 
are: — the accession ahmg with other venereal symptoms; marked 
nocturniil exaeerhalions ; a dark hue of the vascular zone ; fibrinous 
de|xiait (rccnrrin;^ in nodules of a brownish hue, ntnddcd on the margin 
of the pupil »^ well aw on the anrf*LCe iif th*' iris ; and the mar^jin oi 

' Hr. CormidmelV Furmuts bt ila fulUiWH:—H«dpc— OL Tvretilntb. root, one. nujuu 

— VitcL. ikDfun ovt — Tcrv Filmuli v\ ^uUIr gm^Jaliin, KuliiIf'- Amv^il, uiic <|uflL.itur — S^ru]j- 
rorl- nurAJitii uac, -to"" - SpJr. tjivt-niL cmnp itiucLmADt, c. wmi^de— Olel ClannnLoiJiU 
guttu i|UfltaDr- \\. Hiisii^— imi'. un. ter in di«. 



J 



CHAKGES IN THE rUHL AND IRIfi. 



lOSI 



tbe pupil often observt?(l tu be thickeTiefl, and corrugate"!. Tbia fomi 
gtnernlly i& raor« severe, find mixs ita course more quickly, Ibiin the 
iUiojulbic variety of irituj- Trehiiutnt is us fur ordiiitiry eXtiiujjIeH af 
tilt disease. 

Tlif fthr.umatic and Arthritic Iritii is nol of Bncb fre"[Hont occur- 
rence. It la chiirftcteriscd by : — aceesiioii Ukion^ place ulon^' with 
other Bjmptoins of a rbeiimalii? or gouty character; tb<3 vascular zone 
10 of a purplish hut, and not a Jiltle olwt^ured by early involvement of 
the cunjnijciivul veeefla ; the whilish riii^ surroiUidiiig Ibe ci^niLM Is 
more pcrccptitflo in thiB nprcica of irilifl, thfto in any other ; tho pupil. 
cnntrArdng^ inclines to aSHUme an oviil form; and there is penulinr 
proneness to relapse. Treatment consists of the ordinary aniipblo^nMic 
remediL-fi dirtctefl against acute and inflatuuiatory rhcumaliem. Mer- 
eury shonld be given cautiously, and often require* to be cumbintd 
with quinine ilh h tonic ; i]i many CEU^es iis pUice may lio advajitage- 
ouaiy laben by colchicum, giiaiiie, or iodide of potasfiiiim. 

S/rumoita Iritis freqiienrly residts troTn exteaftion of the inflsmmnlory 
process inwards, in CJisea of stiinnoug corneitiB, and ie tbe form of iritia 
most generally met with in childhood. The previously e\is[ixi^ 
opacity <jf the cornea is very lijdiie U> mask the internal and mere 
imporinnt disease; deceiviJig the prat'iiliontr :is \\) its iwir^lcnce, aniil 
Oic opportiuiity for siK^ceshfal tteiilmtnt has passed. Mcrt-ury shunUi 
be used very spnringJy; and, at n conipiiralivtly enrly [H>ricid, the ad- 
miniatration of qainine, iron, i<.>dine, &Cr» with a tonic regimen, ja 
required. 

Cfnmges in iJis Pupil and h^s. 

Unusuai dtfaUtU"H u/ t/ie pitpil is termed Mrfdriosh. It may be of 
idiopathic origin ; or it ma,y be eonncetfd with diEorder in tha cerebral 
fnnctinnt ; it is a cntnmnn symplom <if Amanronirt; and frequently it 
is caused by contusions ; often it is sympathetic nf intestinal imt-Ltion, 
The fldniission of an esceta of liglil to the retina is found to be a 
serious inconvtuienee; and vision isi-unfu^'d and inqiaired acccrdiiigly. 
The reraediid Ireatrncnt uunsihts in dili.rlicni uf the taui*; removal at 
thia, if possible ; u-Jid eubsequent stimulation of ibu part^ by friotiona 
on tha Temple and bmw, and by espohure of the eye itself to ammonin- 
eal vapour. Electrieily and ijalvanisui are also soinetimea useful. In 
tbe idiopathic fonns of paralysia of tb'^ iris, M. 8err€8 recomnicnda 
Moterizfttion of the corneal margin b\ riiliate of silver. In other cuses, 
p«Uiatiori reaults from contracting tlie spa<.e for adraissiinj of light, by 
Bpeclacles darkened cscept at a email o|>eniiig in tlic centre, as in tbe 
case of conical eomea. 

When dilatation of the pupil accompanies amaurosis, of couise it 
cannot be expectetl to disappear, itnleEs the aamnrotic conditien have 
been previously removed, 

Myosis denotes unusnal euntraetiori of tbe pupil. Tbis la one of the 




no 



O0CLC810N OF THE PUPIL. 



cviriHwuiences of Trilis, as we have already s&L-n ; it may also attend 
an disorder uf itie cerebtftl ianctioiis; EonieLinius it la induced by 
habitual straining of the eye on smflll objects — as in microacupists, 
(Uigravcrs, watcbmakers^ Ac. Ordinary and useful virion is necessarily 
iQipaired. The means of cvire consiai in removal of tbe cause. In \he 
ortifiuora jnat enumerated, temporary abstinence fi'om tbe usoal ftvoca- 
(iona will oft^n ^nflioe to r^^Btori? Lhe nornjut »;l[Lte. 

Trfmuhiis Iris. — A trembling, or oscilbitory movement of tlie iris, 
not unfrequcntly accompanies amaurotic nffecliouB ; and seems also, in 
most eases, to be connected inib softening of tbe vitreous bumoun 
It is bat little amenable to treatment; and is eliiefly notable aa a 
siiffioient contra -indication of operative interference, in conneiiun with 
tatiiraet and orllficiiil piijiil. 

Adheshns of (hf. Iris — Sj/nechioi — bave been already considerBd. 
They may be the result of wound, of corneitis, or of iritis. In synechia 
anterior^ comjiletii, and 3ccom[ianiwl with opaqne corner, cnre is mani- 
festly boi>cIess. Wlicn incomplete, and the cornea clear, amendment 
by liie formaliuii of an arlificiiLl pnpil ia witbiu uiir power. When the 
adhesion is partial and recent, it may BomelimeB bo romodiod by mer- 
curials, am? the use of Mladonna. Similar treatment will avail in 
synechia posterior, when recent and pnrtial Gutj wben c<.kmj»letc, it is 
mnally accompanied wlib ojiacily of tbe crystalline capsiile, and it may 
be of the lens itself; under such clrcumslances, amemlmeut of vieion 
can be effected only by an operation directed against Ibu cataract. 



Occfusion of t/ie I'upiL 

The pupil may he closed in vanons waya, Remaining iteelf in a 
iiormal stale, it may lie obscured by (he cornea wbicb has become 
simply opaque, or opaque and staphyloma Ioub. Or, llie cornea re- 
maining clear, tbe iHr may contract during inflammation, and the pupil 
may liecome tieciipiud by organized fiUrinoua dyposit. Or both iria 
and cornea may undergo serious wtnictural change ] as when complete 
pyneehia anterior takes place in staphyloma. In tbe last mentioned 
case, rentoralion of sight is manifestly imimssible. But in the other 
examples, something may lie <lon« by forming an Arfijieiai Pupil. 

liefure proceeding to any hueh o[ienition, however, ccrlaiu circnoi- 
pian*?cB are invariably to be taken into consideration. It must be 
ascertained t—^th at the a^lhcsions of the iris are irreniedi;tble by the 
influencL' of mercury and bL^lladonna; tbal the opacity of Uie cornea is 
permanent; that tbe other parls of the visual Li[)|]aratii& — et-pecially 
the retina and vitremis humour — are in a sounii and. 
tion ; tiiat tbe eyu has not oidy ctiascd to bflj 
affection, but, als^i, that it is not prone 
uf a fresh exciting cause. An niiera 
be inexpedient, so long as the 




UPEitATlONS FOB ARTIFICIAL PrPlL. 



ill 



I 



vL^on with the other eye ; &nd it is plainly cotttr ft- indicated, when one 
eye only is affected. 

Three distinct modes of iij>eration are practised; all implying 
diTiaion of the iris — so as lo make a nufGciuiit ga|i in ii — opposite a 
clenr portion of the cornea- TI^q dosired apace in tlie iris may be 
obt4iined by incision, excision, or laceration. Accordingly, the opern- 
tion is Bsid io 1m? by Ciirelomia^ Corectomia, or Coredialysis, 

The situation of the (mfposcd new pupil rccjuires consideration. 
The centre of the iris is the bt^t [>i>sitiou ; bnt whec tills iJi impractt- 
cnble from ceiifrn.] (iji;vciLy of Lhe cornea itr other cauHet the uasal hitle 
is Uj be preferred ; or it may ho inHiIe on the teixiporal or lower Ecidea. 
Wlien fiiatlc b\kivq the centre, it is apt to be covered by the up|jer 
eyelid. 

The patient, by previous preparation, should he placed in a coiidl- 
lion favourable to the avoidance of inHainmation. 

Cfretoiiiia^ or iinjibiun, la performeil in ciwteB where the greater 
portion of the cornea ik clear, and the iris is apparently in a state of 
tension, with tlic pupil cloned. It 
may be |»erft>nned eilber Uirough the 
sclerotic, or through the cornea. In 
operating tbrongli tiie sclerotic, an 
irifl-kuife is ii^roduced thr<Hi<;]L this 
meTiihraiie about a line from its junc- 
tion with tlkP cumi^a, aa in the opera- 
tion for catnract, aiid tlic point of the 
knife is made to pierce tie im at 
about a line from its tenijjoral margin ; 
the instmini^nt is then carried aci-o»i 
aolerior chamber, to the nasal aide of 
while it ia withdrawn again, gentle pressure ulionld be made with 
ita edge n^ion the iris, the tense fibres uf which when divi^led will 
separate, and an elliptical or ovoid pupil will be llie rcEull. The 
fibres of the iria shonld be divided for about a half of the diameter of 
the membrane. When the lens is opaqtie, a^ is generally the case, 
it should bo broken np at the eamc time. 

In opernting through the cornea, a method praetieod by Maunoir, 
an oi>ening is made in tine membrane by a cataract knifo, involving 
about ft third of tin circiUDference ; into this aperture a pair of fine 
sciasors is introduced, the ptjiiited Idade of which lb tlinist through the 
iri*, while the blunl one la carried betivecn that membrane and the 
cornea. The scissors are pushed on, (ill their fjirtber progrcsr* i» 
aiTfiHted by the junction of the cornea wiih the aclemtic, when thtir 
^blades are brought together, and the irh^ is divided as in the former 

Th 33- 1, CoTTiomin Ihruuph iho srli^rikric. Tin? Inife intmdn^eO— ralber fiirbiii.'fc. 
4i>inifi thraii^^h thp i\*nipii, ><liiiwm^ Hit' Iiii4'?uf tlit^ iiii:is!i:iiu- ^ Tb« saiue aftnr 
nlion, 4, CarediAly&UoT Bvpuratiuii.— From W^iTAKTON Jo?<il 




the 

the 



frnnt of the iris in the 

compa {Fig 35, 1) ; and, 




112 



nriL. 




the apex of vbkb ifl 
v3 Anrd ^ in the 
'ktW 



» 




A*-*- 



MW Ibe cnifc o^ Ifae «iiu TW 

dneedon of its bMB, aad leow ft 
liekt (IV 3d, 3 Mid 3% 

Gurecfomit orcxctvott, k |jn fcc»e d Ai w ^k tke ckmb, in 
wlKre a portiod ^ ilul uMHlnM ia opaqs. WWa ^e pupil 

ooo-ftdlfeecnit, and mlr tke ontie of 
ibe come* oft^qo^, m broad Aat needle, 
or tlbp putikl of a calmntfC kniip, w 
poned into the uitmor cfcoaber At 
!h« lover or <«ter sde ct tbc conett ; 
ihruu^ this Afertoie Mr. Tm^'s 
fine bloot houk is iocroduced, And 
luTing bc«n «nl&ik^W over the free 
margin of ibe I>u|h1, is widtdnum 
thnni^h the opening: Ihe iuclttded ' 
portion oT iris being either excised with ectscors, or illored to rub cff 
with ihe friciion of iLc lida, afier liann^ becooie stran^Uled in the 
wound of the cirniesi. 

When tbe pupil is udhi/rent either tir the c^psiile of ihe leus^ or to 
the ccrnuB, a larger incisiun tli^ii \u ihe fonn^r ca^e eIiouKI bv marje, 
near the junction of the cornea niih the eclcroiic, and 
throiitrh a. cltar i^rtiun r^f the comea. The nqiteous hnmotii 
e&ciij>cH, and l>i ^'-ntrally fitlluwe^l by a [irolnifion of the 
iriM, which fthotjid be increased by geotle pressure on the 
^htljti ; <ir a |H>rtiiin uf it OLHy be dr^;;eJ out of the opening 
by A umall h'titk ; an'X when a bufliciency has been pro- 
truded, it tili'^iild lie pxi-'iru-i] wilfi i\itt curved &ciKSore. Si^meliniea it 
la neceHBary to Hcirarat.i- ihe jvlfif.'^iunti uitli a needk, before the iria 
will ^vrolapw, A|«irlion *tt (lie jju[jllary margin Khonld, if jxissible, 
be infliuied in Ihf^ t*X':\m^'\ juirl, 

Chredtah/ah, or Hi\niru\\'tu^ in |i'rffirmrd wln-n ilie comea isopnque, 
except A hinal] p&rL ut itti cnn:u(iifi-Efjjcc. Ibivin^ made xn opetiing 
ikbout two lineA in lt?ri^lli litnrbi^li l1ii> opafpio meiiihrane, a fine Rharp 
hrtik is iutroduced* which irt fiit'd iti tlur iriw close lo its ciliarv border, 
and behind ihocleur portion <ifllK* c</nirji. When llic hook is wilhdrjuviij 
the iris is lorn away from ita liliary *tllm;liinent till an opening tjf snf- 
Gcient siae is obtained {Vig. i\'>^ 4j, Tiii? |Kiriion of the im which is 
dlBwn oat of the anterior cliamWr, may either he allowed to become 
^lavuUted in tbe edges of tlm inc-inion, *ir mny he excised. 

Thm ofention may also he i>ertormod by introihicin^ a curved 
■Ai^tcedle through the Hcloroiic, ami carrying it acmss the poste- 




nff,«. 



mM 



Mlvftibouk Hi' " ^" ^PtfHTrid, 



KETlNlTJe, 



113 



G it is mode to perfi3rate tbv 
the point downwanb and 



rior chamliei- till it roaches that iKirtion ti{ the iris which (t is wialierl 
t4> separate from its ciliJiry attacLuieot ; he 
iris, and Beparation is eSected by presaina 
ontwarda, 

There h generally a considerate quantity of blood effused into the 

anterior <;LaDibcfr after all L>f thc^t 0|Feratiunii, iitid more or Icsa iufiam- 
matory affection foUotts, Strict nntiphl<>gi*^tif? Irtatment shonld be 
pnrsiied, with confinement in a dark room. It is to be rememhered 
that the new pupil on its first fornutlionf bhoidd seem rather too large 
thao otherA'ise ; there being always a decided tendency to subaeqnetit 
cun traction. 

Afections oftftt Retiim. 

Rttinitia. 

The acute form of this affection may follow direct iiijury by woand, 
or the pressure of a depressed lena» or expostite to intense light or 
heat, or nndne and continued exerlion of the eye; or it may be of 
idiopathic origin. It is iiecouipa[iie<l wilh agtJiiiiiing pain, detp seated, 
ahooLJng throuj^h the hc/i-l, n-^gravated by the sHgbtoBt motion, and 
ofien with delirium. There is very ^real intolernnce of light, with 
lachrymation ; Inminoua bodiew seem to pass before the eyes; vision is 
greatly impaired from the comnjencement; the pnpii is at first much 
contracted, but aJterwurfU l>eco[ne?^ dilated, and remains motienless. 
Then the intolerance of liglil abates, and lilindness bt? comes com} ilete — 
the retina being uo lunger capable ot' obeying the acouBtomcd Btimulus. 
The system is involved in marked inflivmmnlnry ft'ver. At first, the 
outward indicatiuns of increased vascularity are not very appareut; 
but, idlimately, as the affecii'kn extends to the othtr Jeep textures of 
the eye, tiie nenal signs of internal ophthalmia become developed. 

Treatment, which sh;jnld be decidedly antiphlogistic, ictiiiBista in 
eeclosion fram all Btimnbia of both the eye and the system ; blccdiDg-, 
both liwjd nnd general, repeated if need be; piirgHtiveH; cininter-im- 
tanls ; and free exhibition of mercury so as to exert its fnli inflnenoe 
on the syitem. Mere abatement of ihe acute symptomia is not snfB- 
dent; therefore, the remedies ought to be persisted in, till a perfect 
cure is established ; due regard being paid to the Bafety of the patient. 
If the disease be allowed to degentrjite into a chrimiu form, \i will 
nltiniat^?ly prove injurious to (he function of sight. 

By this term \& nndersbjod impairment of vision^ more or less com- 
plete, dejiendeut on change in the rntuia, optic ner\'e, or brain; and 
that change may be either struetorul or functionjil. In the latter cobc, 
there ifl gi^i^l hupe uf curei by suitable treatment; in the former, even 
palliation is ofteri hardly within out power. 

t 





114 AMAURoaie. 

The causes are : — cban^ in the retina, optic nerve, or bmiii, Ly 
the inflflmmttlory process, Hcnte or chrooic ; comprcBBion of these parts 
in any way — as by extravaaated bliJo<l, inflanimfltQiy elfusiun, or for- 
mation of n tumcur ; a coagesict} slate of these ports luduced by over 
exerlion of the eye or brain, hy irregularity of tH>weh, hy hftbJtnal 
exposure to mucii !i^hl and beat, by intemperance, by gout — by, 
in ehttrt, whalex-er teods to caiiae dt-tenni nation of blood to tlie head* 
Sometimes, on the contra.ry, ninaiiroeis is causeJ by want of ttie circu- 
laiing fluid in the eye or in the head ; as in uuses uf anaemia from pro- 
longed lactation, profuse uterino diachiirgc, or tho like. Woiuids of 
the Hiiproorbital branches of tlie fifth n^rve have often been fallowed 
by amauroBis, 

Tile symptomB are : — impairment of viaion, ^adual and increas- 
ing; at first there is perhaps mere obsairiition of sight, hut this soon 
gives plniee to thorough per\-crsion of that function ; otijectrt are often 

seen of crmncoiia pruporliun (ind colour. In the congtativc and in- 
flammn-tory funug, more or leBs puiti is ciomplmnerl of. At firnt, tiiere 
may be intolerance of ligbl ; but ultimately a glare is home ^vith im- 
punity, ov is rather desircil than otherwise. Ocular spictra are seen, 
either constantly, or from time to time, i-siiefialiy after exertion of 
the eye ; iliey may be dark or litmiuous, massy or ecintilUted, steady 
or flickering. The pupil la dilated ; tbo iris la slu^gitth^ and iillimatcly 
motionless; tho oye has u vacant starini^ expreBsion ; and the putit-nt 
actjuircB a peculiar, uncertain g-ait- Often there la eo fixed or det^ided 
pain in the pirt ; but rather a sensation of letisioa and uneasiue&s. 
Sometimes the eyeball has a tremulous or uscillatory motion. On tho 
^bole, the ordiitjiry and characteristic evm}jtoTUS nre, the painful sensa- 
tiona, the im^wiirDienl mid perversion of vision, the ocular apectni, and 
the Btato nf ike pupil. In ftjiplying the catoptrit-al test, th& three 
images of the candle arc seen as in tiie healthy t-ye — a siiflicient dis- 
tinctiun from both glaucoma and eataract. From the hitter it h further 
difitinguiahed hy vision being improved in strong light, aiid impaired 
by belladonna ; by the slate of the pupil ; by the absence of crj-stalliiie 
opacity; hy pervfiffiion of &ight exip^liug — not mere impairment ; and 
by tho characleristic ataro and gait of the putieot. 

But there is no uniformily as to symptoms. In most examples, 
pain ceases on full e^^tablishment of the di^ase ; in others it continues 
unalate^I. In most, the symptoms gradually advanct^ to complete 
loss of sight; in others, independently of Ireaiment, the symptoma 
reach a certftin point and then remain atalionary. One patient may 
continui< tu have izitolerruicG of light thronghmit; Uig majority of Ad- 
vanced Amaurotics, on the contrary, seek a strong light. Ending tbeir 
viaion improved thereby. Some see objects duuble ; this variety is 
called Dipl'ipla. Others Bee but the half of an object ; and this Is 
termed Umnopia. In ma[Ly, the pupil is ai, first contracted, there 
being an originating inQammalory proci^HH prettent ; in nic8t, ultimate 



AMAUH08IS. 



115 



and permnnent diUtJbtioii exials; but, in & few cases, Iba iris eeetns 
Datural in both form and bno^ and ie porfectl^ obedient to the etitDuEns 
of li^hr. 

The nntowaril progress is very rftrious. Sometimes vision is lost 
al once, as when exlraviLsation takes place by sudden ci'ngcslion. 
Sometimes monllia eUpse ; or even jeanj may be ciccupied in the 
gradiiiil decay. Tlie u.3t;ctioii h nic>flt uumraon in the aiidille jwriod 
of life ; and while it eeldom aLtiiukH both ejca at once, both ftre ulti- 
mately tnvolvi'd in the ^rent majority of eaj^ps. 

In the inilaimiintiiry form, tht mofle of treatment is plain; the 
or<liiiary an tiph logistics are Ueinandetl, in Ciisen which are at all wcute ; 
and the Bystcra ought U> be brought, and tnaintitineil fur some time, muler 
the influence uf mercury, whieU often eviEices u slrikiiig control ovi?r the 
dir^Cftso. In the chronic examploB, modcmte dL'plction, fidlowcd by 
an alterative rnurse of raerr.ury, is moBl iikely to prove useful; and 
counter' irritation \s at the same time advisable. Whea congestion is 
snspecied, rtiorkrate depietir>n shonhl Iw pr;ictised wicfi purffaiion; and 
then the nrilinary means are to be taken tor preventing local detenoi- 
nation of blood. If llie affection have followed diiiappearance of an 
aocnstotucd di&charg«, normal or n^it, r(;tnrti of Ih^it discharge ia to be 
nought, ir an atonit^ Htale of the system exhi, a, Hllmiihilmg pl:ii» of 
conatitnlional treatment is plainly indicated- If the disease 1« appiir- 
ently but a secondiiry pymploni, a« it were, uf some cwinlitutional 
malady — as jaundice or hysteria — that malady is to be timranghly 
eradicated from the syBtem, if possible. If iuiesiinal irritation exists, 
or be eii^n;«le<l, it is to be tre*iled by the ordimiry racnna. In ehort, the 
pTediapoaiog nnd erciting causes should, if pfissible^ be aKcertained Hiid 
removed. And this paraniumil indication havini^ been more or leKs 
perfectly fulfilled, certain means are s<»molimeH in luir power whereby 
to rouse the retina to a resnniption of its fimction. Stimulants, when 
applied directly to the eye, or to its neighbourliootl, are sometimes 
useful fur thin purpoa: ; or the tuilermic fipplitatiim of strychnia may 
b« mafle on the temple "r forehearl. A blisltir hftving heen applied, a 
quarter of " grain of the powder ia sprinkled on the [lart, once or twice 
a-day. The dose is gradually increased, nulil a bitter taste is felt in 
the mouth ; and then temporary dJHcontinuance of the remedy ia expe- 
dient, Failin;* strychnia, electricity may be employed, but itfl ujse is 
aeldoiu altendod nilh much benclil. 



Affections «/ the Crr/stalltne Lens rmd C<iptnik^ 

CiitarfTcL 

The term Calnrart is applied to opacity of the crystalline lens. It 
IB said to be leniirular, whrn the disajist^ is eituated in the lens itself; 
fopsular^ when the capside only is opaque ; and capsvln-knlictdar^ when 



^ 



116 CATABACT- 

lw>tb tho lena axiA its capstik* are offocted. The affection may occur 
fit atjy ftgp, and is s-iid to bf* owing to " d«?fective milririrm from iho 
chan^^ which Jtre ffoing on in Ihe yaBcnlar or lymphaiic system." 
Or it may be induced liy exterikal injury of the part. Sometimes it ie 
a congeniul defect. Mt>st freqnenily it ootjiirs ia advance'! years; one 
hign^ among many, of the frame's ^'radnal rkcay. 

The promineiit symptom is impflirment of vision. At fimt, crhjocta 
ftTM? Been as if obpcured by a gatJze or mitit ; this obscuration grarlnully 
increases ; and ultimately Tisinn lr almost, Imt not entirely, lost Some^ 
times uneasy sensations are t;onH"laiJieil of in the eye and forehead; 
more frequently ihe piirt is the seat of no abnormal Bonsiilion, Sight is 
iffiprovefl by n diminution oV light; it is belter at twilight than at 
noon, and also bolter when the patient is seated with bi^ back to the 
light, iban when facing the window; for ihe pnpil, then dilating, per- 
mitfi the rays of li^hl to pass to the retina through the margin of the 
lens, whicb is as yet unob^unid. For & like reason, the nsc of bella- 
donna niaterifllly improves the sight. On looking into the eye, an 
opacify is diacemihle, occupying the pn^il, and situate immediately 

behind it. Wlitiiever delLlH'rH.1e i-xaiiiEo<ilLOii Hy c<MiItuiplHlod, bella- 
danna sh<nild be previotisly applied, to dilate Lho pupil, so dm tu afford 
every facility for ascertaining the extent, and chanicler of the opacity. 
In proportion oa sight ia impaired, the opacity is fonnd to have in- 
creased. It is greatest at the centi-t*; when complete, it is of a grev, 
white, hlnish, or amber hne; and this is not nufrcqncntly coniraaled 
with a dark annidus or ring on iiH eiti^rii^r — ilie hlia<low of tlje iris 
falling on the periphery of the eatiLmot, In ihe most advanced caeoH, 

the patient is still able to distinguish li;:hl from darkne^i,^. The iris ia 
not necessarily impaired in its fnncliuns. Hoih eyes are Beldom 
attacked at once ; but usually bolh are ultimately involved. 

What is termed the caUrptrirol (rsf nf caiaract is comiucted Ihua. 
The pupil having been dilated by bdhidi^nna, iht paiii-nt ib sealed 
with hii^ back to the light, and the surge-^n hohU a liglUi.'d ta])cr in 
front of the eye. In a wmnd organ, tlio dejilli of llie dear pupil 
exhibits three reflecliou-s <^r images, of llie liglii ; mte suj>erficial, bright, 
und distinet, caused by rcHectioii fmni tiit* tornea; one deep seated, 
pale, and indidtiucl, caused by rtflLvnon from ibe iinierinr portion of 
the leni ; and one in tho mesial plane, or bi^twrcn the two f .ruicr, small 
and oljficnre, eaiisod by refleeiion from the iHisterior [lorlion of the 
lens; the two first, erect, move eonneu tan eon sly with i[\v lic^diU-d taj^er; 
tho latit mentioned, inverted, moves hloiA'ly and in an oppoEitt direction! 
In the case of cataract, the middle inverted iniu^'ii is iirsi eitini-niwhed - 
and afterwards iho deep erect one alno Ijci'umos invisible, Ur to 
speak more accurately, " opiieity of thr i*ont<TiiiT pjipAolo prevents ihe 
production of the middle inverted inuige ; and opiu'ity of tho anterior 
capsule destroys the two posterior oneM. In other Wonls, in posterior 
eipsrilar cntaraci, the middle or inverted image is noL mm : in entarnct 



CATABAOT* 



117 



I 



of llie onteMor capsule, and iu caps ulo- lenticular oataract, the anttriur 
tttraiglit one only ia visible." Li amaiLro»s, tlie throe imager art; aln^ayn 
distinct, as in the Boiin'l eye, '* Glaucoma, only when iirnch advanced, 
oUiteratts the inverlpd image; while, in all its stages, it rcHdcrB the 
deep erect one mm'e evident than it is in Ihe healthy eye." 

From glaucoma and amauiuaia caUiraot i^ fLirlii<;i' didtin^iiiEhcd, by 
th(j state of the p^ipil, the site nnd clmractct of tho opacity, tho nftturo 
of the visiun, and the expression and gait of the patient. 

Spurious Cataract is Raid t\} ciibt, when urgaQized fibrin oecupieB 
the pnpil. Thi^ iti distinguished frgm true cataract by being uf a 
yellow or whitish colour; ami by Iha lens being ndlierunt to the iris, 
which in puckertiil, aUered in hue, aud irttgular in il*j pupillary 
margin. 

Cataracts vary as t.] dentiity. Hard cataract is mnst frequent in 
the old; and is characterizx-'d by its brownish or amber tint, Tho 
lens in apparently whrunk in iiB dimensions, and the greatest amount 
of opacity is central. The iris is tree and movable ; the dark ring 
eurruanding the cataract is reujarkably distinct; and in the twiliglit, 
as also after tiic uae of bclladonnft, oIjjccLh may often be discerned with 
tolerable ncmiTAcy. So/t cataract, ctf fluid iir B^ndiluid conniatency, in 
large and hulgingT and completely occupies the pupil. It is moat 
cooinion in the yonng and middle aged, and is characterised by its 
bliiiah-whilc or milky colour. The iriti is clogged in its movementu, 
from the increased size of the leas ; and the Impairment of vi&ha ie 
great- Tho opacity ia ant aKays homogenona j dots or Blrcaks are 
occasionally obiif^rved on it ; and iheso muy ehiingo tholr fomi :iud flite 
from time to time. In what is termed the Radiated Cataruct, tho 
opacity is formed in §trcakh ; and not in i frequently commences at the 
circumference, thence exleu'lin^' towards the centre. This peculiarity 
ia readily observed on inspection; and, aa tan he easily iindersiood, 
visJoji will for aometiuio prove better with a contracted than with a 
dilated pupil. 

TreatmenL — Unfortunately our art has as yet proved impotent, in 
attempting to stay the progress of advancmg cataiact ; and, when it has 
fairly formcl, no faith need be reposed in any attempts at simple dis' 
cuBsion of the o[iaqne structure. By o[>cratioD only can ameTiduient 
be obtAitkcdn The ohstnn:t[ng body uijiy be wholly extracted from the 
eye ; or it luay bo puflbed out of the u^ia of vision ■ or it may bi? broken 
Up into fragments, whieli are expected to be aftorwari:hi absorbed; or 
it may be simply drilled ; c^^ it may have its capsule opened, m as to 
admit the aqueous humour, and thus favour absorption nf the crystal- 
line substance. Before any opurulion, however, is underiakeuT certain 
prelim inaritfi r(?i|uire to be jidjualed, aa in the case of Artiilciul Tupll. 
Wa must first bo satitificd that the eye is in other reBj>tcts toimd ; so 
that, wh^'n Ihe obstruclion to light is removed, there may be a lair 
prospect of viision being restored. There must be no amaurosis, glau- 





UK CATA-ttAL'T, 

uonift, change in the vitreons humnur, ophthalmia, or nffet'Hon of the 
e;'QlM8. The pnlient must l>c free from aiiy marked roitstitiiUoiml 
ftilment. The slfite of the atmoRphere should be mild and favourable. 
While there b a ttderably useful amount of vmon enjoyed \)y either 
ere, it in more pnidimt to refrain fnnu oj>cration ; the rpHults of operft* 
lion being found mtist favournble ^n cases well maliu'ed. One eye 
only slioulii ha operated on at a lime. Finally, by careful regimen, 
*i]id niLMlicinal treatmi-tit if necessary, the sviiteui is brtfUrjlil into a 
fjvvoiirablo Btato, ami ih rendered not morbidly Buseeplible of inflaiu- 
maUon. 

In thu coni;^iiilAl variety an operation shixild In; i^erformed early , 
ulherwiaa the un^tvady rolling inoiian which Lhe eyeball ie ao prooe to 
jiHsume, will prove an inipeiliment to EubsequeDt mterference, tnd to 
(he KNci^essful rcault of c»i>eralion- 

Extra'-tion. — lu the operiilion by extraction, the opaque lens is 
romovetl fmoi the eye through an aperture in ihe comea — in operation, 
iiiieeisiuirily eoinpreheniling^ a cunsiderAblc eiteut of wound, and no 
uliyht amount of injury Oone to the parta. If inflammation can bo 
)ir«*V['utod» Ihrt resnlt in nften nuwt si;e*'essful- But if inftammatjnn 
BU[>orvene, or an accivlent happen to the vitreous hnnour diiriug the 
O|»t*rtilioii, BAffht is kist irretrievably. Many favourable drcnm&iaucea 
rt'i[nire to be [»reseut to warrant an attempt at extraction. Tiie comea 
(thoidd In* su.iiuid, ilie nnlerior cLautber of |>roj>er aze, the iria mohilo 
iiud iioii-adheivuiT the g:lolte prominent and steady, the caUract lenti- 
nibir nTul liarih Tlie i>alieur should be in gi>o.l health ; neither [ile- 
ihorii' Hud iurtummaiory. iior we*k and incapable of plastic esudation ; 
cap^dilo ot ^'If-coultolr and of maintaining the supine posture; oot 
trikiddoil u'itli eoa^h, sneezing, or asthmatic ailments. And thififleiies 
nf ^uatiliChiii^ii^ uev^':ysari]y limita the ojieration by extraction to ft 
minority oi'thii oawb otciitanict> 

Thi* |injkil should not be dilated, otherwise escape of the vitreons 
humour is fAVium^L The itatient is placed before a steady light, but 
with his head slightly inoltiie*! fn^a it, and either geateil, or teciim- 
hvny ; lilt' s*>nnd eye may \k cvkvertsl by a bandage. The surgeon, 
hohlia^ tht' knifi; in \ih ri^ht hai^d. shoiild be plaf^ either lu front or 
iK^biud, mvor'Uhi; to lhe <'yc ffbiv*h is to be operated on, Ae a^tutant 
b\.'\\ o[vus inie lid with hh fotv and middle 6nger?i, at the %Ante time 
Blejhlyinj; the eyeball hy a Utile pentle pne^sure ; the soi^eon opens the 
other eye!ivl, aud a^^ists in steadying the globe, by the fingers of his 
loEt band. If lUi' [^tiont :>it^ his head is secured against the lower 
jwH ii{ the assisiani's cht'^i. The flap may be made superiorly or 
iuferioily, fti^tvrvhn^ fc* it t* lhe rijcht or leA eye vhich ia to be 0|>er«ted 
i»ti. 1[ is uMijilly made superiorly wbea ii i* lhe right eyp, the »iirgetin 
"taiidiuK KhLu^l, aud eV^atiu^ lhe u^^r lid him^lf; vhen it is the 
h*ft e\i\ ih»' Hap is iu«ile infcnorly, the enrgeon bciag seated before 
hi^ l^ttirul, atid di:<|^rv«^n>: th\' l^^tr lid, while the asaiataut raises ibe 



CATARACT* 



119 




The knife used ia the tnangular one, known *a Beer^s. It slioiild 
be lidd liglitly botwet-Q tJie thumb and. f>ointE of Uio I'dI'q and middle 
fiagcrSf the rin^ nnd little 
fingers resting upon tlie 
clieok- Thi? flat edge of 
Ibe point la firRt made to 
tench tlie coru*?a geotly, 
in order to reiLSBure the Rg-ffi. 

palienl, and Becnre fitezidinefia of the organ; it is then entered at 
about a lire fnjm tLe corueal luiirgin, and passed into the antyrior 
chamber in s. perinindi<:ular dircctiun, lost sepflration of tho corneal 
lamina sbuuM take place from the knife geltinjj between them. 
Penetration having been effocted, the direction is cLatiged, and made 
parallel to the mirface of the ins; the knife is then pnshed sttadily 
across the anterior chamber, the [loiiit emerging at a spot directly 
uorresjionditig to that of Ita tntranci* j and tlje stuaily advance of the 
inetmnn-nt is coLiliiincJ, until Boc-tioti of the cornea ifl cotnpleie. 
All pressure ia now ^:l le removed from the eyeball. If the aqueous 
hiimuttr eMca|>e jiremjitarely, the iris falls forward, and is consequently 
brought into cuntact wiih the odo^ of liie knife. In this case a stop 
ifl made, and gentle pressure musi he applied Lo the cornea yet uncal, 
withtmt howcvur wiUidrawing the knife. Thij* ihiiy suLcecd in replac- 
ing the iri^ hiuI tben eoction is coatimied. If iii>t, the t^Difti is nrith- 
drawn, and probe-pointed ficissora are Bubstitnted, with which the 
ffomid is finished.* 

Tliu corneal Beciioii hjiviiig been completed, tlie eyelids are per- 
mitted to close, the eye to rest, and tLe pnpil to dilate, Tbeu, tlie 
lids having btefi gi'uUy ru'0[)enr!n, the bharp end of a curetle is can- 
tiooaly iiilr^iduood bDiiotLlh tlie fl^4[>f und as gently ee [.ujsgible iti&do to 
divide tiie captiule^ Tlie slighetjt i>rj&4ible presstire is then made on 
the upper eyelid — over the anterior part of the globe, just behind the 
corneal margin — so as to dislodge the lens — and nothing more. On 
escape of the opaque body, the corneal flap is properly ai^ljusted, aDd 
the eyelids are iiermilted finally to clotie. Slmidd the iris have pro- 
lapsed, Euddcn enporiuru to a bright light will jtrobably snffit't; for its 
redneliniiT by cauwin^ contraetion of the tiflsiie ; if not, tlio protruded 
portion may he re[)laced by t^entle use of the blunt extremity of the 
curette. The eya is covered with a li^ht pledget of lint, and a km- 
dage. The patient shuuld he laid on his back, with the head ele- 
vated; light and all other stimuli are to bo rigidly excluded; the 
moat Bparing regimen Ja to be cnjuiiie.l, the ai:t of maalifation even 
being inlenlicted ; precantiona are lo bo taken HgainsI cnngiiing, vomit- 

* Or, tecotdjngtc the luethtHlrif Sich«t and udicrej the f>pQraiiun maybo inlcmipEcil, 
4iid poatponed (ill the huuiDur ia nproduiUMl. 



m 



Kih', !W. rxIriLlIuii. Th^ knife tiillhiR fliTough. 



120 



CATAKACT- 





iTig, and fixieeziiig; imtl, if need be, involiintnry niHnnf^ of the eye if 
to be pTovidod agflinst also. If poBsiLle, the eye should not lie unco- 
vered, and exposed to the stimulus oF light, for at least ihree or four 
days, Tbe B}'mptouiB of indnmtnation mu£t be carefull? watched, and 
treated when tlit-y occur; by bkeiling*, purging, aud abstinence — but 
obviously not by oftufloante. Mercury, too, is inespcdicntj lust ii pro- 
vent siicli *?su<lation aa is necessaiy for ih** healing nf Ibe comea. The 
period of inflammatory risk having passed, the eye ia gently and gra- 
dually accustomed to its wonted stimulus; but exercise of its full func- 
tion is to be very slowly reauraed. 

Depression, or Couching, imjiUes downward displacement of a solid 
oatflraet, whiuh it ia not found ospcdicnt to exlracL The pupil hav- 
ing been dilated by bt^lladonnii, the jjosilion of the patient ia arranged 
as for extraction. The needle used for this pur- 
pose is the on*' kuown as Scaqm'n, and which is 
curved at its point. It is pushed through the 
sclerotic, on the external tide of the comea, in 
the transverae asis of the eye, at the difltAiice of 
fl line from the corneal margin ; this point being 
selected in order to avoid tlie two divisions of 
Yig-if'. the long; eilijiry artery, which vesecl usually 

bifurcates at a distance of two or three lines from the corneal margin; 
also to avoid w<junding the retina and ihe ciliary body. ^ ,^ 

The iieedle having entered, is piisbed steadily forwards 
into the anterior chamber, between the iris and the lenK, 
By depressing the himd a very little, its point is brought 
into contHct ^ith the upper part of the lens, tbe con- 
cavilv of ihe iuptmment being opixif^ed to that body. 
By now elevating the hand, the lens is depressed 
towards the bottom of tha eye, gently and stcuddy ; 
nnd tbg inatmmont, having bfen allowed to rest there fi^ 
for a few moments^detaining the displaeed body, till 
the vitrt^ous humour closes over it — is gently extricated 
ftud withdrawn. Tbe eye is now closed, a piece of 
wetted hnt, with a hght bandage, ia applied, and llio ' *ip:-4i- 
ordinary precautions ugainfil inflammation are to bf udopLed, as aSte/r 
exiraetion. 

Comparative facility of iierforniance is in Eavour of depression. 
But the manifest objections are ; danger of chronic inflammatory' affec- 
tion, in conee^iuence of the displaced body pressing u[K>n or irritating 
the retina and ciliary processes ; disor^'a nidation of Ihe viireons 
humour; and the iKtBeibillty of future escape of thti lens upward*- — 
it^in ti> ohstrnet Iho tnoifimisBifia of light. 

Rcclinatiim is a modiflearion of depresBion. Tbe iustrumcnt n&ed. 



1 



CATARACT. 



12t 



I 




and the mniiTier of introducing it, are the Rmne an in 
depression ; but tbe Icns^ infttead of he'uv^ com- 
pletely dielocnted and p:;8hGd donniA'^Lrds, is 
Mmply made tc revolve partittlly, so aa to turn 
its superior mnrgui buuk^'unLi iitlo the vilreouH 
hnmour ; while its anterior Borface is directed 
upwards, and remains nearly on a level with 
the lower edge of the pupiL Ijeaa injury ts 
done ti> the reliua thnn in depression; but reob- ti[. *a, 

stiuction of the pnpil is at least equally probable, 

ITie opemiion to promolo absorption, or Dissolution, is praciifled 
when the Itiia ia of fluid or Btmifluid consistcnct. The procedure is 
wmple, and easily performed, hut requires refetilion ; and thy reKuU 
IB tardy Jind may be uncertain. The object is, to admit the aqiieouB 
humour (o a free and general contact with the substance of the lena — 
ft circumitance which cAperleuce has showo to be conducive to absorp- 
tion or solution of the latter. When breaking up is intendedj the needle 
is intr<>dQced aa for deprerifliun. Its point having reached tLe p^ijali in 
front of the letiB^ ib made to diviJe the oiipGidc by a slight mtating 
motion, and also Vi break up tho lens into fragments. If the lens be 
fluid, no division of its substance is neeesmiry ; it efii:ai»es at once into 
the acjueuufi humonr, on its capsule bein^ opened. When of roft con- 
Bistence, a few of the fragmeuta often lind their own way into the 
anterior chamber; if not, they are gi?ntly placed there by the netdle ; 
for in that l'«ality absorption or Brjliition ecenis to advan<.'ti more 
rapidly than behind the jHr. Care must be talcen, however, not to 
dislodge the lens forward in a mass, or in bulky fragments ; otherwise 
untoward inflammition may be induced^ in the iris and other parts, by 
prefianre of the lens upon them- 

At tlie firat operatiui], tlio luns ia dividid but slightly. Many deem 
it Bnfficient to divide the capFmlv only ; and certainly il ib vtgW not to 
attempt any dispbicement ; when the operation, however, requires to 
be repealed, the lens may be more freely broken up. A few weeks 
are allowed to intervene lietween the operations ; and aE^er each^ ordi- 
nary anliphlo^Blic prec;iUlions are to be adopted. 

Tiie ojicration by drilUny is jierfonned tbrouglj the cornea* A 
etfftight needle ia enlorod near tht corneal aittrgin, and paeaod throngh 
the pupil into the subRlimce of Ihf- lens, Havintr jieneiratcd into thia, 
to the eileni of about a sixteenth of an inch, it is mlated frecdy, and 
carefully withdrawn. The proceeding is repeated from time to lime, 
00 in the breaking up; on each occasion a freah part of the lens kdng 
chosen as tlie dte of puuctare. The object \a to adndt the aqueous 
humour; and, by its agency on tho lens, gradual abaorption of that 
body takes place. 

Af^er removal of the lens, in any wuy, a convex glas^ rcqiiircB to be 

Kilt. 4:^. Itei'liuatinn.— Frvm VUiinTOR JoNJ^ 





122 



JIYlJROPbTIlALM[A. 



atljiisted to the eye ; in firder fully tn restore vision. Tliis la the daij 
of the optician. Oa\j let it be the Hurs"eon's care not to permit any 
Bucli acljiiatnient, and resiimptiozi of the fbl] exercise of the organ, 
until at least two raonthts have elapsed after the operation — arid more 
esimdiillv if thhl operalion Lave Xmnn hy estractlou ; for nut until then 
will tko cjo be Bofe from accesflion of iu£ammtitoiy dieeiue. 



If afier removal of the lens, hy operation^ the capsule become 
opuqiie, and occnpying the pnpil, obBtnict vision, it may be got rid of 
in cue of three ways, Ii may be extracted^ ihrough l miimte aperture 
in the comea, by a liook, or by small forcRpB, It may be detached 
at its ciliary niELrpn^ by a uec'dlf, anJ tlepreKtierl, Hke a lena. Or it 
may be crucially diviJixI by the n<?eillti ; and tht? Raps Jihrinking from 
the centre, may leave the pnpll patent and fiafficieutly free to admit 
light. 

Afftctiom nf fhe Ihmiours of the ^ye. 

Hydrophih aim la. 

Dr/ipsy ofihe eye may depend on excess of the aqueous humour, of 
the viireoitB hiimonr, or of both. In tlie fir^t <;fise, there is tension, 
promiijent't, change of funn, and iiicrea&i^ig Jiohniosity of the coniea j 
the iris is channel in colonr, and imjiaired \d mobility; the pupil lb 
dilated ; vision is ranch afRcted ; Ihere is a sense of fulness in the eye; 
and move or lesR IjeailaoU ii^ compl;uned of. 

When llie vitreous humour ia iiicreiifed in qnantity, enlargement 
and tension of the whole eye occur \ ibe ins is molionle^T ^^^^ arched 
forwiirda^ the aclerotic is Hlleiiiialed, and has a bluish or broViU 
appoitraucQ ; vision is wholly lout ; nnd ihe pain is J^ep-Goul^d and 
seven.*. Ultimately ihe eyi'hall jirntnidc-s betw*'^^n thp lidf^, iniliLmea, 
and iilceratfK; or rupture lakes i>lace, with purlial evacuation of the 
hum ours, 

Pallinlion is in oar power, by cvacuatiuu of the redundant (Inid — 
by punemrf of the e<irnea or sdt^nnio, nr by im-iwon of iht former 
tL'Xtiire. Sum(?tiinca thi^ progtcKB of the disease may bo dflayt-d^ if not 
arreste^l, by counter -irritation and cons titutiimiLl treatment. 



Si/nrh]/sts Ortifi. 

The tenn Si/nchysts dtiiotcs a dtQ»;icTicj, and uimatural fluidiiy t*f 
ttiL- \'ilreonfi humour. The oye is shrunk and fl:icdil ; the iria is Ir^ 
innhius ; the pnpil i« motion I ef^s^ and viaiou is pilher impain*'" 
Knl uuFrequeiitly the lens IxTomes o^juqus. The disi' 
regarded as incurable. 



OniTHALMlTIS, 



123 



I 



Glaucoma. 

By Glaucoma is understood an amaiirolic state of the eve; with a 
gtceiii^ij ')pacityj bebiiid the i"ipil, foacuvB, and Jteply sealtd. Ac- 
cording io aomo, thib state is mniiily atiribiitabls to nflvctma of the 
retina; according lo others, tbe choroid emit U chiefly iin|dicat*d; 
while a Mrd chisa arc of opinion ihut chHrii};e in the IciriH anil vitreous 
humour i^ the principal chwbg of the disinder. It in pn>Wblc that all 
these tcstnros are more or loss involved. The prominenl dii<l charac- 
teristic ay:ijploQ[8 are, luipmruient or lost iif fti^ht, ptniianuNt dila- 
tation of tlio pijpili green diBcol oration of tho vitroou^ hniiiour, and 
in the advanced stage of the <Iisease opncily of the lena. Diagnosis 
from cataract is marie eas/j by obscj-ving that tht opacity is more 
deeply scat4;d than the lt^n.4; and that it becomes iiidititinctf or even 
invisihle when viewed kterally. The caioptrical lent shows the three 
iiuogea uf the cnndle at ilrsl; by and l>y the middli; Invtrted eue is 
extin^niEhed ; but the deep-eeated erect imago generally romaina 
throughout. 

At the cotnmencement of tbe disease, amendment may aometimei* 
be obtained by local depletiiin, countci'-initalion, alteratives, and a 
mild inercuhal rourse, or exhibition of tlie iodide of poLa^sium. If 
^uiv or rheuaialic syniplonis esisl — as is not unrre<pieiitlv tie eaet^— 
t\m ordinary apprftpriiLlti trtMitment ia directed agmoHt that particular 
state of sysJeni. The lulvanced funii is incurable. The disea^ seldom 
occurft, except id those of mature age. 



Ophtftahtitis, 

TliiH term, in its correct acteplatioa, dctiolca involvement of the 
entire globe of tlip eyo in infiammalory dit?*?ahie— an affection of much 
danger to s true tit re and funcciorj, aa can be readily nnderstood; and 
one which demands the most carijful and active treatment. The oidi- 
Dary results of this iutiammatory pi-ocesa are opacity, ulceration, or 
Btaphjloma of the cornea; adhesions of the irifi^ ^I'ltli contraction of 
the pupil ; cataract; and oi\tn comjiltle destruotion of the organ of 
vision - 

A vejy severe form of this disease occurs in puerperal women — 
aoraetimes in connection with tlic niiili^ant childbed fever — sometimea 
independently of this. The symptoma iire generally of ihn highest 
intenfiity, vishiu is rapidly imnaircdj and often there is great cbeniosis, 

Caj^a OL:ca!>ional ly occur ivhcro the iufljiioniatiou goes on to HnppiinL- 
tion ; the eye becoming a pblegmon. In hucL circumstances, gruat 
ridief is experiencod by opening the abBcess. 




124 



TUHOUllH. 



Wounds of the EffclaU. 

These are very commoQ cairses uf acute oph thai mi lis. And, 
accordingly, tlieir Ircalmenl must le carefully cooducled in order to 
tiTcrt diBiiatraua leaulla. If for«igxi matter lodg^ in tlie inltrior of tlie 
eye, autiphlugiKtics will ftvail but little, eo long u the foreign body 
remaius: the glolc vill su[iiPtirate, bursty and collapse. It is an im- 
portant iuflication, tberefore, to ascertain tlie presence and nite of a 
foreign botly, and to effect iLb removab But tbe same difficulty U 
encountered as la ilie case of tlie brain. It is difficult to ascer- 
tain either tlie sile or presence of the foreign inatttr; aod, even when 
these are [>lam, it ie often vi^ry difficult to effect its removal, without 
mast serious iiijury to the or<,'-an- In rei^fard to prog-uoMWj it la impor- 
tant to Lear in minrl th.-Lt there may be foreign matter in the interior 
of the eye, without any apparent eohitii>n of continuity in either the 
cornea or sclerotic. For, the elasticity of texture may at once close 
the ehtum ia the tunic, and conceal it from even minute iaGpectioD. 

Entozoa. 

The FUaria medinensis has been fecund buueath the conjunctiva ; the 
Filaria cculi htiTiiitni in (he lens. Jn the latter testurc, also, have been 
fonuil t\n: Mowtsluiiui lentt's and the Diattfttia ucfili. Tliu Ct/siiccrvtu telrB 
celltilosfe has more than cinee occupied the ao tenor ohamher \ it may be 
removed by section of the cornea. 



Tumours. 

The eyeball h liable to be the seal of two kinds of li;monrj boih 
malignant— thti medullary, and the mc^laDotie. Carcinoioa i& tare. 
Tbo medullary tuutour is most common at an early age, and eeenu 
usually to originate in connexioD with the retina; growing from the 
bottom of tlie eye, occupying the cliambur of the vilreons Immonr atd 
rapidly making its way externally. Loss of visiun is early and com- 
plete; llie lumour ia its first Blago can be seen diuilv, through the 
pupil ; and the pain, cachexy, and other si^& of the incdullury tumunr 
are prett^nt to testify its ehnracter. When tlu' cuata of' the eye 
have given way, the tnm our increases more rapidly than before; a 
fungiiB ia tbrown out; and this may assume the heuuirriiagi^ tendency. 
The end iw death. Care can be allempted in but one way — hy 
exiiqiation of the eyeball ; and that only at an early jwriod, when 
tho diflciuio is con6oc^d to the iikteriur of the glube j aiid ^vcn jifter 
reon»vnl of the globe, the disease frt-qnently rt'tuitiB flgnin io the uptiu 
iierve ; eventually destroying life. In the advaufed stage, all operative 
InLcrference is contra-indicated; reproduction ia certum ; acid the pro- 
gTVin» of t[i4! ditteaBc, instead of being arrested or retarded, ia likely to 



ESTlIirATlOK OP T13E EVEOAIJ.. 



125 



became accelpratrd. Tnrl^-ei], the ciuies itre very few in wliich the ope- 
ration hati proved llioroug-hly sncccBBful. Once I h.id occasion, on 
*ceotint of false aneiirimn Ht the Lend of the arm, to tie ibe hnmcral 
artery of a gentleman a^ed thirty-three, wlnij at the age of nine, 
bad undergone extirpation of llie pyeball ou acconnt of Diednllnry 
ttL]nonr;*aud in bim tbere bAB u ever been the alightest^ymptuiii of 
tetnrn. 

The melajiolic tumour Ejcnerally occurs after the middle period of 
life ; it slowly fills \i\i the interior of the eye ; is seen liinij biuck, and 
bil^ngf, thnmgh the iiiijiil ; nitimatety thinning tlie coats, and forming 
dark coloured exiernal projections of the sclerotic; attended ^iih pain, 
tension, and early leas of Tiaion. In &i>int cafiesj care ia rei^iiiri^d not 
to mistAke tbe 'license for himpTe i*tnphykiTnfl of tjip selrrotie. The 
only cure ia extirpatiou of the eyeball, and thtb should be done at 
afl early a period as po^blc. 



L 



ETthpaiion of the Eythfdh 

This operation may he rct^itired on account of tuTnour of the eye- 
ball ; tumour of the orbit* involving' tbe globe secoDdarily^ cancerous 
ulceration of the eyelids, inviTlving the globe, or destroying the whole 
of the eyelids — as formiTly explaineii, Tbe commissure of the eyelids 
hftvitjg been divided, at the unter angle, so as to afford spacp, the 
globe i» laid hold of hv a volbclhi ; itnd b)~ this instrumenL \a steadied 
and directed, througUont the reoiainder of the proeodure. A straight 
bistoury is entered at the mar^n of the orbit, and made to move 
round, to as to detach tiie innscies and other parts from the bone ; the 
point, however, being used very carefully at the bottom of the orbit 
lest perforation of the thin orbital plate pbtinld occur. The optic 
nerve is then cut acruss, and the tumour ^^itbdrawiiH If there be 
noHon to Buppect iiooeunl atlenufltinn of the bon^j — perliapa ^lartJal 
deficienny — it were no unwise precaution to effect the ilppptr dissi-^Ltion 
by tbe bandle of ihe scalpel. If the lachrymal gland hiive eMcai>ed tbe 
general removal^ it may be seized by a h<Kjk, and disjicctcd away; but 
this is not tthsoinlely necesBary, Having become satisfied of tbe entire 
removal of the diseaecd stnicinre, the caviiy is sjxinged clear of blood ; 
doeeils of dry Hot or cliarpic ure plaood so i\^ to fill the oibit and pro^ 
ject w^iaewhat beyond the miirgioj ami a retnining bandage is pasned 
around, wiih guflieienl firmness to arrest bleeding from the ophthalmic 
vessels. After a few dajs, the dresting is gradually luidonc and 
removed; suppnration it^ established ; granulation t^nccccJs ; and the 
granulating wouiid ia to be treated in the ordinarj' way. Alter cica- 
triaalion, on arti£cial oyc may be adapted to tbe eockct- 

* Edinbnrgti lUidical and Surgical JoumAl, tdI^ xix. p. GL 





126 



STKAalSUtJS. 



Cuttffenital Df-fidenci/ of Uie Ei/ehall. 

An intcrcsllng- esamjile of tLia occurred to me some yeara ago- A 
girl, Btnimous, and of MniBions pnrenlage, laboured under coujuneli- 
vitia, wliich pmved very obstijjale, and had alrendj |»roductd cunwidtr- 
able Qpiicify of bi>1h o*irneo*. The mother, o.itnrnily of an anxious 
temfM^mnit'tit, Inul her every thought engmnspd hy the Rtn^e fif iHs 
child — then an only one. She a;,''ain became prestiant \ and Ftill per- 
ae^ored in bet watohful nursin;^ imweanedly, and, if possihle, with an 
increafled Bolicitmle. 'i'hv fiecond child waa born at the lull time. It 
provtil a male, viell-forriied, and seeiniii^ly perfect In every way. Bnt, 
or oiiening the cjeJiflPj not h veHli^ of I'ithcr cyeliall conU he found 
The lids were perfeolly nonnal in Uilli form am! Hize, hiit gave no 
dgn of tjlobnlar projection l>enealh; iuiii on Djieninr; ihem, red, fieehy, 
mncous-ltMiking mcmUane^ fliit ;iiid loose, w^a found to be tlte appa- 
rently sole occupant of ihe orbits. As the child grew, the congenital 
deficiency remained nnalterpd. 



Sirobfsmvs. 

Squinting may affect one tye, or bolh. Very frequently hulli are 
implicated; hut one tmly in a minor degree. The inime*lialo cause 
ohvJuuHly de[ten<ls on iniiarniorious aetinn of tlie recti miifcles. One 
may act excessively, while ilG Jinta;rn[ust retains quite ila normal cha- 
racter^ nod dipphieement is cffectL'd by the former. Or — na there ie 
good rcaiinn to believe frcqut^iilly happens — one relaiiiR its normal 
coudilior, while the other is enfeebled, or altogeiher pandy/ed ; mid 
displacemetit U caused hy the former. The ortlinai7 raiieties of 
Bquinting are the Coiivrrgcnt, looking inwards; the Divtrgt^t^ locking 
outwards. The former Ih by much the nintc frequent, 

A great advance hn.^ been maJe in tlio trc^ilmcnt of this deformiir, 
by having recnnr'^p to division of the tmiFclf on the siiTo towanla 
wbich there is dispkecmenl^ati oj>criition fiiigm'ptKl hy Slmmeyer, 
and first performed by the laic Dr. Dieffen- 
bach of Berlin. The patient is placed as 
for otber opbthalmic operations. The eye 
whii:h is not the Huhjtcl of In^aLment in 
cloKCfd \ and thi> pulicat is maile \<y turn the 
affected orjjan in the direction op|Kinite to Ihia 
of the sqniut. A fold of conjunctiva, between 
the cornea and tbe loigle of the eye, but nearer 
to the latter than to the former, is then seixcd 
' and elevated, by means of common diasecling 

fcrcepa ; and is divided by a Eiroko of the suiBeore. By one or 
Iwo touches of llie Hci&sorfl, aided by the forceps, the subcnnjimc- 
Flff. 4A^ Ran nf the eje, showing IhclhiP of itidflinn in tti# pmuitncdvu. 





tiTftl areolu" tiseae ia cnt, and tbe mufcTe exposed — at that point 
^vhere it ceases to be Heahy and logins to be tendin-jiis. It may 
eitber be ^thered up by ibe lurcep&, or elevated on a blunt hook 
poAs^d bcncatb. It ie Ihcn divided completely. And it ts mell to 
make, at the Bamc lime, a dean disAfction of the ^prcUic, for flomo 
little diaUnJ^ on either aspect of the mnBcle ; eo &b to dtviiie any bands 
of fibnins or areolar tuaue, vbicb mi^ht olbemise }xct retentlvdy im 
Uie malposition of the eye. If tbe orgun prove iinsteailj Jnring the 
operition, it caav be expedient to oonirol its moticnR by inentts of a 
flIiArp, abort, double book, inscrt<^d into tbe sclerotic conjunctiva at a 
m£b dtsiauce from tbe corneal margin. Tbe operation over, and all 
indtmmentu witbJraivn, ibe paiient ia directed to lo<jk as be formerly 
squinted. If he find a difficulty in re-elTectiiig tbe dbplucerDeni, ibe 
imniediate result of tbe operation may be considered aa folly atlAini'd. 
Bnt, otherwiae, it is necessary to make a more free division of ibe 

tenures implicat^l ; in all ca-s^a, however, taking c*ro not lo occation 
aji iui£i?e(nly exopbtbalmoa, by (tarrying aifcb division to un nndiits 
eilent. The eyt is covered np for a day or two; and moderate anti- 
phlogislics are used- tJnloward inflammatory ret^idts seldom occur. 
Tbe woond may uraic by adhesion. More frequently, it heals by tbe 
second intention. Sometimes a fungous graniilaliim furtns ; this is 
removed by the ecisaor*, and ia siibst<inently kept duwii by gentle 
CftcLaroiica. Aftt*r a fe^v days, tbe f.inclions of ibe eye nre to bo 
reaumeil and tbey sboiild be bo arran^d as to ^dve the urgun a haliitiial 
movement in tbe direction opposite to tliat wljcrcto it \va?> fornit-rly 
directed. Indeed, this exercise or training of tbe eye, subseipienily to 
the operalion, is a very essential part of tbe treatment ; and should bo 
begun at an early period after the operation' — abnust imuiLidintLdy ; 
otberwiBe an inipfoper reunion of ihei divided mn^le may take place, 
and muladjustment of (he eyeball K^ restdrud. 

Occasionally the cure Is more than complete; B'pdntin;^ in tbe 
opposite direction being threatened. And were tbo other rectus mumble 
DOW to be divided, unseemly projection of the eyeball couhl not fail to 
bo produceil. ForLunntely, it is often fnifliciciit In e\ciHe merely a 
portion of tbe conjonctiva near tbe cicatrix of iho wound ; tbo contrao- 
tjon of tbifl new Hore^ in healing', lending to re>ttore the normal pusilton. 

SonietimeM it is sufGcieni to operate on one eye only. At other 
dmes we are compelled to operate ou both, For» when both eyes are 
implicated in fejiilniin^' — though in very uneqnal degrees — it will be 
found (|uito iijipiiABilde to restore paralluli>jm In pi>Hition and motion, 
if tbo myotomy be limited to llial org-an which ie uiost prominently 
affected — let tbe division te ns extensive iia it may. 

When operalion proves in all respects successfid, not only ia 
deformity removed; the function of sight is also materially Ijenefited. 
But all RtiuinLs do not require myotomy. According to the cause and 
circum stance, tbe treatment varies. 




12S STKABIt^MUa. 

Strabisrans may be con^caital. During early ndolpaeence, attempts 
are to be made io remcJy the evil by Jiio exercise or traiuiEg of the 
organ ; wben ono only is affected. The ffl>und eye is to be cohered up, 
for some hours in the day ; and the other, employed eicliisiTcly, may 
in time be compelled, m it were, to lunk straiglit (ipcm the objects of 
Bight. But cftre mn»t at the sarae tiiue be tak^D, thnt the sound eye 
do nut suffer from imdue confineraeiit nnd disaae. Or a pair of Bpec- 
tnclcs, or gi)o^g!ea,may be worn occasionall}', through which the patient 
cfcnnot Bee with loth eyes, unless they are direcled iti a piirallel man- 
ner. When such means fuib myotomy may be had recourse to, 

Bijmriliug not unfrecpieutl/ iw the reaulL c?f iuillatiup. Tliis imist 
be corrected by breaking i>ir (he habit, and removing the patient from 
cireumstnnces likely to induce its re[ietition; alao by the reniediftl 
exerciseof the organ just noticed. The like treaiment is aviulaMe, when 
squinting has been induced hy the presence of marks on the nose or 
cheek, to wliich the eyes aj'e from time to time directed ; wbL-n it has 
followed on » loui^ coufineme^it u^ the pHtienl lo one i>o&lure, perhnpH 
ounetrn-ined : ^vhon il is the result of using one eye h:Lbitually and piiio- 
fiilly direclEid on smyll objecta, as in cerlmn mechanirnl prnfi'Sfiioiis. 

In children, squinting is not unfrequpntly c<»niiectcd \^:tLl gastric 
aad intestinal irrita.tion; and is remediable by purgatives, alleratives, 
or anthelmintics. In such casej^ the fitrahi.Hnius Ia almost invariahly 
convergent; as can lie readily underatoud, when it is remembered hew 
clooely the sixth pair of nerves ifl connected with the eym(}atlietio. 
Sometimes sninnting- is huL a sign of general disordi^r in the systj^m ; 
and disappears, along u'ltli the other symptoms, under appropriate con- 
stitutional treatment- At any age, it may be the concomitant of impor- 
tant cerebral disorder. 

Not niirrerpiejilly, squhitlng occurs as a sequela of some hifLtntlle 
diHeaae. In KUch eaKca, the affection is of an atonic character; and 
may be mitigated — perhaps removed — ^by a general tonic syHtem of 
treatment, by the application of strychma to the tcrople and forehead, 
or by the passing of el ectr^j- magnet ism through the part 

As a gi'neral mle^ the operation BhiuUd not Iw performed, until nlher 
means likely to ^rove remedial have been found insuflieient. And 
ill the CELse of ihc female near the age of puberty, the opcriitioti should 
always he wiclihtdd, until the ciktam^niE^ have apjteared ; iriitt^iouch as, 
on this occurrence, rapid amendment and removal of the deformity i« 
by no means imlikeiy to occur. 

KsQi-isiL— J. C. Soiindo's, TTcalise on Hnmc Practical Pnints rclutJog to Ihc Dl^enses 
al th*; V'V^ ^i1 iA l<t»nilitn, 1810 — J. XVat<lroj; Tite Alorlii*] AuiiEoniv uT tEiu IIuidbu 
Eyo, Tol. K Ldinburi^h, 1&08; \v\. li. Lviiduu, l:*l«. — B. Trmtrj, A Synnp^ia of tlip 
Kfleast-s nf Ihc Eyt nnd tUeir Tn'*lmtnl, M cJ. Limdun, l&'ifl. — fi. J. Gvih'-ie, Lcc- 
tJtrcA an (he Opernlivi: Surgery nf lUe Kvf, l/imlniit itfiii. — A. WaJMUUi A Cuiiijii^mliLan 
of thtiUisMMaoriheHumanEyt^adal F-diuliiirfe^li, 16'ja— /?, h/iMrfnorr, A Tmai« 
on llie DisoiuKw ^if the Kyo, 2 vol^ Lnmlnn, l^"!, — T. Tj^teP, A FmiHii-'ftl Work on tli« 



: 




8TRAB16MU3. 



129 



ItiKUea of Ihfl Eje> &c., 3 tdI§. London. IStO-— W, l^ackensu, A TrauU^ Trc&tiBe oil 
tlw DiKaflM nf iLfi Eye, 3d *!d. Lun-Itfn, IS*0.— M'. fan^rTtcry A Trealifie on tbo DijiCMW 
of diA EjT\ 2i1 nl Ijimlim. 1A41. — S. LiTtalt. K Mnnu&l nf the Diwoaeji of tlicEy^. 2d h1, 
FhiUdetpliui, l&4fl.^7'- irAarfon ^onea, A Manu&l or OphlliJilmk Mtdicinv and Surgery, 
London, [047- — A.Jacob. A Treati-^on InlLimnutiDnfl of\he EyebaU, Ac, X^iiblia, l&id. 
— J. Datrympigy Pathalagy of the Hamsa EfB, Leadon, now publinhin^ in partl- 

Fnancn. — .1, A l>e"n»ira, Traiio (Im MaladiM dcs Tens, 4 toIb- Pbtth, ISIB. — 
J. Skhel, Trail* i!e FOphlhaimie, 4c,. Pflrifl, lfti7.— C'orrftn 'Ji* ViV/arrf*, GuMe Pmtique 
pour TElnJi? et Ic Trailemont dcs MaladJM da Yeux, 3 vols. Tnri^ ISOS.— Tef/jmii, 
Miinucl TrflUque iht MalaJits divn Ycus, Ac, Taiif*. 1&*0.— -i'/- P. R";/nct/ii^ Trnitrf 
Plulowpliiqiw? el Cliniqn© a"OphUi*itmoloyie, Ac. Fixrip* 1^4+.— /Vera', CJiirurtdo Oca- 
biire, ParUj 1844. — I'cnnarrej, Irait^ des Afdadieii des Tciix, Parfp, 11^7. 

Germas,— fl^', I*hre von den Augenkraijltheilen, 3 eola. Vicnno, 1B1:J-1S1T.— 
C. B. WtUer, Die Kranhhi^iU^n dea Mcnuctlitlicn Aurw, 4th od Berlin, IftlO,— >'. ^. 
Von Amtnon, Zcitothrift fiir ophthidnmlogiQ, DroKilen nnd HflidiJbcTg, lS30-3&.'i7- — A. 
Awfif, Leiire von dt^o An^nkranbheitfn, Vienna I8<(i,— >/- C Juertgken. Die LehrerOD 
d™ AuKHikraixkheiJen, ad ed. Btrlia, 1&43. 

Italian.— X. 5carpn, Saggio di OBAervuiDnl anllc Principali Malattie degll OcchJ, 
FuTifl, laoi ^ or Tran^lftUon by BrL^j^B, iSlS. — G. QwodH, Annntaiiool Pnitiche flollfl 
Uftldtti? degli Occhi, 4 vo]ji. If Apigs, isig-lB30- 





130 



CHAPTER VL 

AFFECTIONS OF THE NOSE. 

Fracture of the Nasal Bofits. 

Fracture of the nnsal bones ia the reHiill of eitenml vioIeuccT directly 
applied. It may be tiliier Bimpk or comminuted; and Ibc latter form 
is of frei|utiit c"ci:urreiicc. It may^ be cither Hini[ile or cora pound i and 
tho lattfcr form miy be constitiiteJ by ivtjuud of the integimient, or bj 
laceration of the iiitcroal mncons membrane, or by a coinhiaatioa of 
both circnniHtancta. Deformiiy, by displace mtnt. is a v^ry prominent 
feature of the injury ; the eiiglitcsl manipulation Bnfficea to delfct crepi- 
tation ; and this sensation is often greatly extended, by an emphyaema- 
tous condition of ihe ariolar ti&snej in tUohi- ciiaea in wliich the mucous 
membrane haa EUstaincd greater injury than the Bkio. Swelling and 
diBcoloration oeciir, to a greater or leKi extent; and nsually pass 
laterdly and downwards, to tlie eyelids and check. 

Replacement is easily effected, by passing a paii of small dressing 
forceps, or the ordinary polypus- forceps, shut — or a goose qoill, blow- 
pipe, director, or female cathctci — iuto the upjicr puj-t of the nostril; 
prsEsing outwards ivith tlie inBtniment, bu aa to restore the nomjnl 
position of the fragnJif nts ; and at tlie same time modelling them into 
their proper place by the fiagers of the other hand applied externally. 
Sometimes, indeed, it may he in onr power to improve on the original 
elevation and to impart to the organ a more pleasing contour than it 
origiually possessed. If any binall fragujeuts be complettly detached 
and exposed, they should ha at once removed. No retentive appara- 
tus \% neceSvSary ; for rcdisjdnccment ir not likcdy to occur, tinlesH 
under reapplication of exiernal violence. lint if bleediu^ prove 
troublesome from the mpmbrane, it may be necessary to plug tiie nares 
gently with lint. If tliere be wonnd of the soft parts, it ia treated 
according to ordinary pTineiplts. Aud, in all cases, the rti[iii6ile pre- 
cautiuns are put ia force against the acc<:Esion of inflummation, and the 
rJRk of eryfiipelae. 

J^lp^tma (f the Noae* 

By this lenn is nnderstuod a by pert rup hied condition of tlie integu^ 
msnt aud 0ul>cuLantious adipoee tinaue of the apex and "''■ 



ulir> ■ 



LIPOMA OF THK NOSE. 



13! 



occurring but iu the mule, of advanced )^earB, who has hvod froely, 
Whea tlie enlargenienl is parlial arid of iiu great iulk, no operative 
Interfereuce ia reqiiireiU It ia aiUficiciit to attend to regimei), aid to 
the stale ot the general syfltom, so as to prevent, if puseible, furthei- 
growlli ; aad direct medit^iil treatment may he np^rlipd 1o Ihu organ 
itaelf, with a view towards restoriDg it to a normal state- But when 
the growth is large, It provoa a eerioiis incotivenience ; interrupting 




vision, and interfering unpleasantly with the spoon and the wiiie-glasit ; 
and, la conBcqiioncOi surgical aid may be naked, and granted. The 
rpdundant growth ib to ho cnpefully pured awny. A finger haviug 
been placed iu the nostnl, bo aa to djstead the part, and facilitate dis- 
Bection — while, at the same time, division of the cartilage is provided 
agaiuBl — the scalpel and iijtceps are carefully uwd, so as to remove 
the whole of the changed integuments- The bleeding ia coueiderable ; 
but IE quite amenable to arrest by cold, preafiure, and ligature. Some- 
tioeB the parts are go dense as to preclude ordinary use of the liga- 
ture ; in which case, if pressure fail, the curved needle ia te be 
employed. Cicatrization is tady ; hut, when obtained, is satisfactory. 
Apparent reproduction may take pla^e, by growth from the surround- 
ing Integument, formerly uuafiected; hut the cicatrix itself usually 
rcmainR firm and dopreeaed. 

Fig. 44. Lipoma of the ddk. 




I. BKPID. SMALL . 

I RATlo^J . Soft. 

ANO GENTLE, 



COMPRESSION, ' 



PULSE. SLOV^, FULL. ^Of/iETfME^l 

rNTeRMirrENT, 

RESFI RATI ON. 5TEKTEK0i;S 



\ 



/ 



1 






i 



132 



POLTPCa OP THE NOSK. 




Polypus of the Noac. 

Nasal polypi are of various kinds; simple-imicons, and cyetc^- 
mucoufl ; fibroofi ; and medullflry. The first Hre, fufLnriatolj, of most 
^ ^1 frequent ocourrenci^ ; and usually are 

found adlierent to the invPKtiug mcm- 
l>raDe of the superior InrLiauled bonei. 

The sjmptonia of the common mucoaa 
polypus are Bufficienlly clmnicteristic. 
Tbe patient feels that something luniBUal, 
and apparently flcflhy, ia occupying the 
nostril ; i^aIU tn blow the nose are un- 
nsually frequent, and can lie but imper- 
fcL'tly obeyed — pn^age of air through 
that nostril being found to be much ob- 
btnicted ; there is a preternatural amount 
'^ of mucone discharge from the part; on 

attempting to blow the noee, a groat portion of the mucous seeretion ia 
thrown into the pharynx ; there is a eonatant feeling as if there existed 
" a cold in the head ; " very frequently, there is lachrymation, the extre- 
mily of the niisal duct being comprensei by the growth, or the lining 
membrane of the duct being sy nip alhizi ugly involved m congestion ; 
and thcM uncomfortable circumfiljineGs arc nil nggnivateil in damp 
and vftriflble weather. On looking into the nfjpfril, thp tumour is 
seen; and, wh&n the Bpeculum ia used, a very difilinct explorition of 
ita bulk and form may in uioat instances be effected- M'ben the mass 
has attained to bume considerable sii^e, it renders itself Apparent, by 
projecting on the upi^er lip. As it enlarges bnckwarda, denfm'Ss may 
be produced, by pre.^nre on the Eustachian lube ; and giddincsfl may 
be occasioned by cumpreBBinn nf the jugiiliii-. The *jeuse <»f smell is 
necessarily much impaired; and bo in many cases is thiit of laete, 
Speech is indistinct, and snnfHing. In sleep, the patient is a habitual 
and sonorous snorer. After a lime, the countenance may undergo a 
formidable change ; Ihe nasal bones becoming gradually disjoined and 
expanded ; giving a very unpleasant breadth to lids p-irt, and establish- 
ing the condition which is ordinarily termed " Frfj^'s FaceJ' Then — 
and often, also, at an early periiKl of the ease — pain is complained of 
in the head, especially in the forehead. 

In the minor eases, it is essential that difignoBts be accurate- 
Symptoms are not trusted to alone. The specuhim roust be employed, 
so aw to exi-use the naAal cavity j enabling ns to ow:erla:n whether tlie 
obatmction depends on nascent polypns or not* For the discaae is apt 
to be simulated. There may be merely a geaeral congestion of the 
lining membrane. Or there may be a bulging of the septum \q one 
aide, with or without congestion of Ihe membrane on the convexity 

Fig- 46. SiiDplQ mucous polTpl, lecr growing in the nawl pifls«gefl. 



POLYPlfS OF THE NOSE. 



133 



ofthQ hu]ge. There may be obsceFs forming Lclween the Bcptmn and 
its investing membrane. Or there may be a hypertropliied condilion 
of tbtj spongy bone. Any of these circumBtanceg may produce more 
or lew ucflusiuQ of tbe nostril, increase of Uihcharge, eimffliug of 
speecli, and moat of the ordinary symptoma of poljpus. Bj use of ibo 
Bpeculum only can tba true condition of parts be determined. 




IflUcre be no polj'piia, no forccpe are n:<jtLired. For I'ongestlon, 
abilrftctioa of blood and nitringent lotions are sufficient, with robnrftnt 
treatment constitutionAllj. Abscess of tbe septuni may be prevented 
by leeching; when formed it requires evacuation. Displacement of 
the septimi, and enlar^ment of boue, call for no interference. 

Removal of ibe common polypus is effct^ted by twisting and cvul- 

BlOQ. Catu ia ttikcn lo ^PP^ the forceps accurately to the neck of 
the (nmour^ no as to insure romoval of the fnlirf nins^ ; nnd gentle- 
nesB ifi used, so as not to endanger a^-Tilsion of btme. The forceps are 

Fift- KL Fmg-fsiMf; lUi« polj^pi eauBing much deformity bycxpaniion of the bonu^ 
■mlcfaiuigQornlitJve pMitiua In tb« Hoft puts- 



r 



134 POLYPUS OF THE MOBE. 

well tootlieil firmly juinled — and maybe further Bccuwd by a pin 
between the bUdeti^ ro as to prevent ihcm paH^ing eacb other during 
tho twiBliag raovenicni; simngf, yet nol so bulky as those commonly 
in ase— less thmi the *' drtssiug forctpfl" of the ordmnry pocket-cftWh 
SotDetitmja forc^-ps conBideraUy curved are usefid id reat^hing Bmal] 
Koft pfilypi which not unfrequently prow from tte upper and front 
part of the nsLres, and which the ordinary inatniment t'lLsaes hy. Tho 
tumourB Irtiing generally numerous, more than one operation is usuaJly 
required, to effect eradication of the whole ; and of thia l3ie patient 
should be wuriied in the fii-st instance, to prevent disappointment, 
Aflor temporary clearance of the nostril hoa been effeeted, the cavity 
is plugged with lint ; to arreat bleeding, and prevent the access of cold 
air to the raw surface- 

A second operation ts not attempted, until the inilammatory reenlts 
of the former have completely subsided \ nor until examination by the 
sptculum baa revealed the fresL crop of luinourtt, wiiuewbut advanced 
to mature development. This may h© after weeks or niontha, 

Ahct the nostril has bei'n dnaily cleared, tbe use of an astringent 
is advisable — such ae a solution of Kinc, nitrate of Bilver, alum, matico 
— with a view to prevent reproduction, and rcsture the mucous mem- 
brane to a sound state. The following form is often found very suit- 
able: — Sulphate of Ziuc half a draebui, Tiu<;lure of Galls one dmcbm, 
Water eight ounccK. 

If evulsion he found to cause inordinate pain, with inflammatory 
symptoms, the altachments of the polypi, in tbe re|«aied operation, 
may he severed by probe- poiii ted sciBsors or knife. 

The dcn«s Jibrous poli/pits, when originating from tbe posterior part 
uf the uiisal cavity, projects backwards, la of a somewhat pyriform 
abapci aad hanga pctiduloiia in tbo faucce. For removal of Bucb a 
tumour, the use of ligafnre w hy some thought suitable, A long 
double loop of wire, catgut, or stniag cord, is passed through the 
affected nostril. The neos? is caught, rb it appears hi the posterior 
faaccB, by forceps introduced through the month. And then, by 
fingers or forceps, the loop may be curried ovtr the fundus of the 
tumour; bo that on drawing tho cudes hanging out of tio noQtri], the 
nooae may be run tight upon tbe upper part of the growth. This 
having been done, the nasal ends are passed separately, llirough a 
double silver canuhi, wliich is then pushed into the nostril nntil itfi 
extremity rests on the polypus. By puihng tho ends, the noose is now 
completely tightened, so as to strangulate the ma^s ut Its atlachmenl- 
And the end& drawn tightly, are secured through ringK placed for this 
purpose at the anierinr extremity iif tho caiiula. From time to time, 
a renewal of the tightening may lie ha^l recourse to. The tumour at 
last drops away; and is tither swallowed, or cougbed up and discharged 
bv the mouth. 

Sometimes, however, tbe uoowug yf the mass cannot be bo easily 



POLYPUS OF THK NOSE. 



135 



accomplish ffd. The <lonble lijL^atiire h&ving been p&ased as before, the 
loop hanging out of the month is <livideJ, vo da to conatitute two single 
ligatures, Tbe oral end of one ia passed throiig-L a lonp single canula, 
and is CMrierl carofiilly under [be base of the luraour on ore side. Id 
the same way, the corresponding' end of the olber Hgutiire in manageil ; 
so Ibat tbh ligature pa^si^B round tbe tumour ou tbe oppoBitc aide. 
Tb<* directing camda having been Ibeii wiibdrawu, ibe cii^ublt form of 
ligatnre is reetoredj b^ nnitiDg the oral ends in a firm knot, Tho 
nasal ends are now drawn ; and tht* noose ih mn iight on tbe tumour, 
at its upper part., aa before ; tightening of the noose being effected by 
means of tbe double canula pasKcd tbrongh the none,* 

But a dense and firm polypus may occupy the anterior part of the 

iiarea ; lir<jad In its jitlachintiiE., and Grmlj Liuiied wilb butb periotiteuiu 
aad bone. Such tnmonre experience* baa d^clftred to bo prone to 
degeneration ; early becoming vascularf soflenin», and ultimately 
assuming the medullary characler Removal tbtTcfore is highly 
expedient- and, to he t^ffectunl, it must be Ijoth early and com|dete. 
Ligature will not BufBce. The morbid itnicturc must bo cut out, along 
with the parts from which it htuiiigr^ a^al wiib which il h ii^iniately 
ineorporattil. The ftporatiijn ia formidablo and severe — hut not tho 
less ex|)edient. No fiied rules cau be given to giiida the operarire 
procedure. It may be p^v^ille to disclo^ the tumour and its Bite 
sufficiently by simple incision of the nostril- Or it may l>e necessary 
to remove a portion of the sujierior maxilhu-j- 

The iiitdttllary and malignant nasal t^l>'pi ^""■y ^ regai'Jed as 
incurabli!. By tbe iimir tho caeo Iiaa bcea Biibn;itti-d to the anrgoon, 
the morbid ntniclure has bo extended as to render its tnfire removal, 
by any feasible operation, itu practicable ; and we content ourselves with 
[illation. If niiLch distress be cecosioned by occlusion of tho nostril, 
the ftoft obstrucling mass may from time to time be pushed away by 
the finger c.ir prube ; but even ihis int4;rference must be very carefully 
practiaed, |pst troiiblcBome homorrhugu L-imao. Also, lot na bowarc of 
mistaking protnision and pointing of tim tumour, at the internal can- 
thus, for fistula lacbrymalis al>iat to form. 

The crcctilf tumour has been found growing from the anti'rior nares ; 
not merely an inconvenience, but dangerous by tendency to bemorrtiage- 
Cure has bt-en obtained by destruclivw ai*plicatiou of tbe actual cautery 
to the diseased tiissue.^ 

Rhinolithei, 

Rhinolithes, or calcidi of the nasal fossae, are coEnjwsed of muais, 
pbosphate of Ume, and tbe carbonates of lime and magnesia; and are 
most frequently found in the inferior meatus. In volume they vary 

' BftOinK, Ijtn-xiL, Nf>, IU5W, p, 316, 

f ^YMl!:t Londun jlhiI Cclinbur^b HoaUily Journal, l&lZ, p. 191. 

I Dublin QiioTturlv JnaniHl, Feh, 1S17, y. fll^ 





136 




EPISTAXIS- 



from a pea to a pigeon's e^^g; ia colour l>kc"fci frrey, or white ; of rou^b 
BUifjice ; and oflen CLintftiiim;^ a foreign body, or the root of on inciaor 
tooth, as a nucleus- SomelimeB they create but little disturtwince ; in 
other coses dirnnlc inflntnuiatory disease h lit up ; in some EoppiiratJoT) 
occurs, with profuae foetid dieohargc ^ and the Mptum may uhiunitflly 
givt^ way liy nlppratioti, the whole organ hecoming seriously <ieforme<i. 
The eye luo nay sympathize; and that serioiiEly, Treatment is by 
extraction of the t>iFending substance ; and this is to W cfTccled either 
by forceps or by scocip, as may seem most eouvejiienl ; aiitiphlogiaties 
beings aflenvards cruployed to subdue espilemenl.^ 



By this term i>^ underslooJ, an inordinate hemorrhage from one or 
both nostrils. It may be the immediate result of an operation for 
polypus; it may fulloiv external injur}', wilb or without fracture of 
Llie nasal bones; it may be one of the untovard resiilla of mcdullhrj 
fortualion, within the- naeal pavity, or connected with it; it may be a 
critical depletion, of nfltural occurrenci?, lending towanls resolution of 
an inflammatory process; or it may be the eonse<i«cnce of a passively 
congested and hemorrhagic state of [he schneiderion membroae. The 
common bleedings of tlie nose, in adolescents, caused by plethora, and 
tending to relieve the system from that unsafe omdilion, ecorcelj come 
under the designation of cpistaxis ; usunlly tho bleeding iu not inordi- 
nate, is in all rpspects safe and beneficial, aiid certainly requii-es the 
adoption of no means for ils arrett. 

Our first duty when crlled to a case of alarming hemorrhage from 
the nose, is not a( ont^e to al tempt to cheek it ; but to determine whether 
such an attempt 1)0 advisaMc or not. If ihf bleeding be habiinal, tn 
a rubnst and plethoric patient, not very far advanecd in ytara — if it 
lie at nil critical in its history, as connected with sn inflammatory 
attack advancing in some adjaceat jiart — if we are told that the patient 
has been subject to giddiness, or other afFections of the head — wo are 
not to interfere, unless eTi<lent signs exist that a greater amount of 
blool has already flawed than ihe system can well bear, and that 
further luss i\oi;Id pmbably be attended with liazaidons conecquenees. 
Then — but not till then — we endeavom- to prevent continnanco. The 
patient's head is elevated; and coU is applied to the nose, foreheadj 
and back of the neck. All stimuli arc forbidden, and absolute rest 
and qnietnde enjoined. This treatment failing, astringents may be 
taken into the nostril, and applied to the bleeding surface, by injection 
or by iosufflfttion — Ru&pim"& fstyptit', n wihilion of ■/M\q or alum, tur- 
pentine dilnto, powdered gall nuts, matio, Ac. And thismelhi^ofarrPBt 
may be assisted by obstruction of the anterior nares; either by com- 

■ DuiAnttuAv, AiuiiJ*«itala<rbLrurgi«, Jnlv 1940 i ud Huikuig'a BHtmjiv 
p. [ii6. 



Ei-IETAJUS. 



137 



prossion. or hj stuffing- the crtvity firmly with lint, after tba styptic has 
beer enffit-ionlly aiij)iie[i. Lately, it Ujls been proposed to elevate the 
ami, or arms^ and tu retiiio tiiem raised above thtf liead; and certainly 
this proceeding would eccm occasion ally tu contt'ibulei at least, towards 
the suCL-esafiil ti/flxdt ; iwrlaftiifl in consoquente of greater puwer being 
reqiiiroU to propyl the artenal bUvod upwards in the urtii, and 1e!sb 
coneeqiiently being expendisd on tlie caroiid circulntion — as tlie origi- 
nalor,* Dr. Ne^ier, iniat»ineK ; or periiape in consequence of tile 
iucrea-st^d facility of venons reliirn in the eulxdavijui vein '* hurrying 
the return-bluod in the jugulars, and thus deriving frum the bleeding 
vesaulB of Ibe nose," 

When eucb minor means fml^ it ia iicotsflaty to plug the narefl, 
Ixjth anteriorly and ]»i>Rteriorly. A long- Ktout lignture is passed 
through tLe itOHtril int^t the mouth ; by meann i>f a f!csible bougie, a 
loop of wire or catgut, or a apringed instrument made for the express 




F!c-47. 



purpose. To the upper part of the oral extremity of this IrgaturcT a 
portion of 8pODge or a dossil of lint is altachci], of tufGeieat sise to 
oDclade tho posterior u^ieiiitig of tho i~io»:tril ; and by pulling the nasal 
extremity of the iigaliireT thin obstrncting Kubstance is firndy impacted ; 
the extremity of the oral portion of the Hgatnre remaining still pondent 
from the momh. The anterior iioslnl ia then filled with lint, pushed 
firmly from tlie front. Afier three or four daj s have elapsed, the appa- 
ratus IB removed, gently. The anterior plug is withdrawn by means 
of firecps; Iho posleriur ia eitrccted by pidling the oral extremity of 



" Anliivp* *ieiicrfl1w rti- Mtflitine, June 184:i, 



¥\gi- 47. The am'sliiif; of tu^niorrhftge l^ plugging. A pliiff, w, uboul to bo ItNlgoil 

in IIk' pnttotiiir iipLrii, liv nieaiii uf (he liyaturc, ft. 'I'bin having liren t\oar, 

Hcrwordv pUt^vd In lJj« (ronl iiArefl, tlic blevdiiig fn>iii tfml DoHtril u Mvlj- 





138 



THE PASSING OP NASAL TUBES. 



the li^lure, previoae rlislwlgment, if need be, heing effected by the 
caatiuna imsiiitig of u |)Tobc jiflssei througli the nostril. Scmelimea it 
IB necessary to jtlng both n<iBtnls ; Lnt, generally, the hemorriiage prD- 
ceedrt frcQi oue m\ly. C<jnslitntio]ial treatuient ib not forgntten ; more 
oEpocifilly if tbore be rooGOa to mip{KiBe that % bemorrh&gio teDcIeucy 
etints in the Kystem. 

Another method of plu^^n*^ ihc narca has been lately proposes! ; 
by inaerting a Inhe of vulcanised caontchouc, and distending thid either 
by air or water.* 

After jihigging in any wfly, grtit care Khould bt* taken that all 
has been (horoughly removed. Seritnis conaequenceB, both locttl and 
cbnatitiiHonal, have reunited from foreign matter — irach as a dossil of 
lint, or portion of sponge — having been left impacted. 

When s}-ncopc has occurred from epiKiiixiSj in an elderly patient 
prediBjwsed to liead affection, we should be very carefnl not to excite 
premature ajid excessive reaction, otherwise cxIravaBation within the 
craninni in not unlikely lo fuJlow. The head is not to be pif^ccd low, 
AH in restorati<in from ordinary Byncoi>e, but should be kept elevated ; 
and atitnuU should, if possible, be avoided. 

The passiag of Nasal Tubes. 

Flexible tobos may bo readily enough passi'd along the floor oF the 
noetrilw into the posterior faiicGfi ; Jind Ihenco they may be directed into 
either the larynx or esophagus, as circinnBtuticcfi may require. The 
former destination is necessary iu attempts to rewlore breathing, in 
cases of suspended aninmlion ; the latter, in order to intHnluce mitri- 
tive ingesta into the stomach — an in eut ilironl. If» in liic latter caae, 
the tube is to be left permanently inserted, the [)fla^^agc by tlie nose is 
plainly preferable to that by the mouth j avoirling profuse Balivation, 
arid much discomfort. 



Foreign Bodies in the No.strils. 

Foreign bodiefl may lodge ftccideutally in the naaa] cavities; more 
frequently tboy arc introilueed wilfully, by the- yoimg and inconsi' 
derate; peas, beads, portions of pencil, and snch like substances are 
very commonly inserted by the thoughtless child. On the foreign 
body deeidedly disappearing inwards^ the patient is alarmed ; and 
probably maken dej*perale efforts lo estrude it by the fingers but with 
the effect only of pnbhiug it further into the nostnl. The parent or 
DiirEo is now made aware of tho circnmstaace, and by tliem similar 
efforts at dislodgment are mad(f, again with the effect of causing a 
deeper lodgment. By this time the foreign substance is beyotid the 
reach of the eye ; and its site is further obBcured by llie slight bleed- 

• L*ncel,Na. ia7n,p,579; also Cyclop, of PracL Surgtry, p. KH- 




CONGESTION OF THE SCHNBIDEWIAN MEMltHAKE. 139 

ing whiuL haa probaViiy taken place during the al>ortive efforts at 
extm^on. And in tbis coTitlltion the siir^oa fiLrIa iLc cage. It is well^ 
in tlie first inBtftnoe, to inject a stream of warm water into tlie noHtril ; 
it cleare awaT coagula, loosens the foreign body, and may effect it* 
eJtpulsion. If notj tlic probe is i\t be used, iLc patitnt'^ bend having 
be^n firmly secured; and the beat wiiy of accomplifiUing thiSj in the 
chitd, is to place the head firmly between Liie kneca of tbe operator — 
mUesa indeed anaistheBJa be enjplojed, as in most cases it fchould be. 
By the probe, used gpenlly, we first ascertain the presence and site of 
the foreiga substance — for it may have passed outwar^b, Ly the raoath, 
or downwards by the pharynx. Having diecuvered the fordgn body, 
tho dat end of tLe proi^Cf slightly bcnli or the ticooped ond of a director, 
or a curette made for the puri>o&ef \& pastied down [ipon it, and insinn- 
ated past it; therij by raiding the handle of the iiistnimcnt, and 
bringing the point to Iw^ar upon the jxjsterior aspect of tlie foreign 
snbslauce, the latter is dislodged forwards, and may be readily rcmoTed. 
Forceps, bovrcver dim, are very likeJy to fidl. Tbey stize tbe ante- 
rior part of the body only ; and, sljppiTig, have the effect of oaoGing a 
firmer and deeper impaction. 

Congcaihn of ihe Schnelderlan Memhrane. 

The ILniiig niembraue of the nostrils \s lirible tu become tbe seat of 
a minor ioflammutory process ; chronic, and unimportaut aa regards 
atrnrtnrftl change ; bnt tronhlesoma and inconvenient by its conlinu- 
ance. There are redundancy of Bccretion (often fittid), uneasy sensa- 
lion, and a feeling of stuffing in the part i not iinfreqnently the tone of 
voice is considerably iaipaircd, and the sense of Kmell may also be ren- 
dered imperfecc. Many of ihe Kymptiiiutt of mucous polypus are pre- 
aent ; and careful exploration by the nofial epccubiiu i£ ncceasary, to 
tiuare B.cfiiracy of diflgnwda. If ilie affection be at all of an acnte 
nature, a fcw l4<c<jh«i may be rc<iiiired more than ouco — applied directly 
lu lli« loeuibnuM by meana of a suitable ^'iass tube ; and in the piiseive 
form tif ooDgMtJon, leeching may also lie expedient, once, to unload 
lh« ¥«Mdlft uT liw faxt. Then astringents are employed; sulniiona of 
ttilcaitv «f "Jw, Mljyhate \j{ zinc, chloride of 6ud<i, ahiiu, malit^o, &c., 
•ad CLuM an* pali4*r»l]y peivevereci with, either singly ur combined. 
Bui ifi dU om* ma eqieciol regard must be liud to tbe slate of tbe 
gvoenl ■jtfciM UMiaJly an atonic condition is found ; aiid the greatest 
benefit b dofred from Kustained exhibition of the chalyleates. In 
very ruauy cant-if, indeed, without this tonic general treatmeni, all 
locki care w<fui4 prove of but little &vaJI- 

AbBcess of the SepUm Nmium, 
^ may flirm beneath the mucous covering of the ecptum ; 



140 ULCERS OF THE NOSTItlLS- 

ond, vbea acnte, the inftaminatory procpSB which cauH^B it \& usually 
the reaiilt of external violence. The chronic furm may be independent 
of all apparent esciling cause, occurring in a patient of bn>ken-down 
ay&tem — i>rohiLl)ly ft viciim of tie morciirio-flypUilitic Uint. The 
bulging swelling- is apt to Hiuinlrtle thti growlli tif polypus. During 
the nascent stage, leeches are to he applied tn tlie part, and other 
suitable an ti phi optics employed, to prevent suppuration if jioBHlhle. 
VVheu TDiLttcr has formed, an evacuating incisioa cannot be made ton 
Boon, in order to fcave the cariila^'e; otherwise great defonuity may 
cDtiuOr by iL Mliug in uud ahnQking of tic moeb prominent port of this 
important feature. 

Ulcers qfthe KoBfrils. 

1. Simple ufcerativn of (he Bchjkcideri&n membrane is liable to occur 
innu the orilinan' exciting' causes of ulceration of mucous tissue ] es- 
}>uaure to cold, contact of acrid matter, [rrilaliun communicated from 
diflensed teeth^ Ac. The treatment accordingly consists, frHti in 
taking away the exciting cause ; seclusion from atmofipheric cxi>osure» 
discontinuance of snuQ- taking, removal cf diseased teeth or slumps in 
the upper jaw- And then, according as the ulcer manifests the 
infiamed, irritable, or weak characters, the applications aro blimd and 
sonlliiiig, or nitrate of silver in substance or sohtUon, or varioua gently 
stimulant lotions, 

'2. Mercurw-Sij]}iul(ik ulrers not nnfrer^nently funn in this situation; 
of a eecoudary, or, more commonly, of a tertiary cfiaracter. They are 
oliBtinate, and likely to resist ul! mere loail treatment. The more im- 
portant remedial agents are thoBc which atlect the system ] e*ipecially 
the iodide of potassium aad earsiiparilla, 

3. 0£te7ia,— ]iy this term is luuh'rtLood an unhealthy ulceration 
of the lining meiuhrane of the nose, with affi*eti(»n of thti subjacent 
bone — caries, necrusis, or l>olh combined. Discharge is jirofuse, and 
offensive ; the ulceration tends rather to sjtrcad than to lieal ; portions 
of bone from time to time come away ; tlie uoee sinks inwards, and is 
more or less di:formed ; boib ariiciilaliuii and lespiratiou arc interfered 
with 'f tkud ultimately thu general hiialth may Hori:>uRly give way. 
The noBft! boTsen themaelveH may perisii and e?rfo!ialo ; and then the 
deformity is not only great but almost irremediable. The peculiarity 
of this nicer iu, timt the ulceration is of a spreading character — simply 
acute, or slowly phagedienic ; and tliat tbo lon^s aro more or less 
ext^nsLVuly involved. In the adult, few examples will be fomid ia 
which tho obnse of mertjurvj hr aypliiliiic or otlier aiimentH, cannot 
be traced out as the paramiHint cause. In children, the fliTeclion 
would seem lo he connected with ibe strumous cachexy. 

Treatment is mainly ccnslilutional ; as in tie btmple mercurio- 
syphilitic sores, without affection of bone. Be^dea the iodide of 
potassium, and sarsaparilla, arsenic is faund a very useful iaieiiLal 




ULGEnS OF THE NOSTRILS* 



141 



reineily — etcndily persevtrotl with in Rniftll (Iooth, Iq obstinnta cieee, 
beiieRt has oftc^n reKiiltfd from t-xtiibilion of the liquor liydriod<itia 
aneuici et hyiirar^'ri — a powerful alterRtive.* The local npi^hcationa 
are necessarily varied. At find, bland nnd tepid injectitjnfl are aJvis^ 
abb ; afterwards taose which are stimulant and jiUerative. A ^veak 
aolntiou uf urscmc;! boliitjoiis of tlw iiitfalc tjf silver, aEilpUali^ of ziiic, 
Ac, jnny bo employed iia eircmnatancos eocra to indict ate. Tbrough- 
ont the eurfl, the chloritleK shoiihl bp lifted, at lensi occasionally, as 
correal ives i>f f*Elor. By somo, llie following oombinalion in held in 
high repute; an injection composed of from one to two drachms of 
thlorldf} of lime, nibbed up with thirteen onncea of decottion uf 
rhalaiiy niol — btrained nSiei Htmiding half an hour. In bcrofiiloua 
cases, ordinary aotiatrumoiu cciistihitional treatment will, of cour&e, 
not be npglpcted. 

4. Lupusy or Noii me Umgfrf, Is a coulirmed plia*^da?nic ulcer; 
commencmg u^Himlly in the npper lip, or nt tbo exterior of llie nasflt 
cavity; spreading upwards, inwards, and around, but more in breadtb 
than in depth ; often healiag at one part, while it eitenda nt amdher; 
ultimately invaWiug the bon^s, denuding' them, and iudiicin^, by 
caries or neoroBis, such deforming r^sidtn ae at an earlier period follow 
on ozrena. In advanced cascH, llie soft piirts of the nose, and nut a 
little of the hard, may be wbolly destroyed ; while an iinseemlv chasm 
ba* also been made in one or b<dii cliceks. The deslnictive proeefis 
may advance siill more extensively, procbidng lUformiiiea more aiid 
more hideous, and ultimniclj proving fatal by hcoIJc oxhinjslion. Tho 
djfiPAstt (h most ciminum tn adtiltJii — of the pofirar Hort, ill-feJ, ill- 
clothed, ficrofuloUH, or tainted in system by mercury, and loo probably 
also gived to liabits of intemperance. Sonielimes, however, it aibicks 
the nu>at careful and currecU As in other phagedienic ulcers, tiio 
affection may Iw either chronic or acni*;. 

Treatment w partly conslitHtional — such oa recommended in OKnoa; 
partly hw:al, consisting of &iicli applications am are fimnd mmt suitable 
for arreal of phagedieua. An escLarotic, such as chloride of ainc, nitric 
acid, or nitrate of mercuiy, is first emp%ed ; and then the &ore is 
subsequently treated according to life cbana^tcra which it prescntJ^. 
When it threalens to become irritable, and verges again touar^ls 
phflgeda-na, a weak fioladon of arsenic is found of much servico. Of 
escharolii^si, the fi]l<inde of line ia perhaps most employed, in the form 
of jiatite ; and is espcL-ially useful when bone baa become affecle<l ; for 
it seems lo hasten csfobaiioa Occasional uw of the simpler chlorides ie 
aa estvetdial aa iu oKwna. Somettmcs repeated Wching is useful* 
After arrest and cicatrisation, the grealest constitutional cure is etill 
required; olhcrwiae rcaccHBion of the diseaao w cxtremGly probable. 

5, Cnna^rot'S \dctr may implicate the nose, by cxtt^nsion from ^ 
face; or may originate in the fonaer »te- It is amenalile to bo**"** 
treatment — early removal by k:ijfe or eacbaroti<*, or by iHJtb. 

-^ Jovnul of ir«dicil Scknce* Septemt>cr ] 644\ p. 'ja. 





1 42 HIIIKOI'LASTIOB. 



RhinoptagticB. 

When the soft parts of the nose bnve been destroyed, jiartially or 
wholly, by woniid, ulcerEktiou, or slotighiogf they may be restored in 
801110 mea^(ijv« by transplanting a compensating amouiil of cnlaneoua 
and subctitoDcoiui tiasucs, borrowed from an adjoinbg part. Wben 
nlH-ralion bi^ l>een ttie destroying agent, no reelorative ojienxtion ia 
ever to be attempted, until siitisfactory evidence have been afforded 
that all nlctration has ceaseii, and Is nikt very likely to relnm on tbe 
Application of a commoD exciting cause of infliLmmation. Uader 
any circinnstJULces, it is plain tbat the seqnela of lupus presents a 
Diiich less favourable pm^^isisi than nbea tbe cicatrix iv the result of 
womul, or imy otb^-r auiplf casnalty. 

When ftlniost ihe entire orgnu baa bten removed, its restoration is 
Attempted aa follows: — A piece of card or leather is ^aped of the 
reqninxi dimensions, to cv>ns(itute nt-w alsB and apex ; tlic eolumna 
bein^ lel^ for an ivtter proceeding. Anil this outline of tbe new struc- 
tnre ^luidd always b? ratlier lou large tbuii oLln'rviiso, there Ixitng 
groat tomteuL^y Eo tbrivol by abeorptiuD, after the flap has beoomc fixed 
in its new Ktoality. The edges of the cicatrized sore, on which the 
born>wcd flaj) is to be adjusted, are mwle raw by the fenife. The onl- 
lino of llic ^ap is then Uid flat on the fGrehead ; the fnndns pointing 
upwarls, the ni-cb ri-stin-,' bcrwi^en the eyebrows. It is there steadily 
jioM liy an HssistAnt, while iJie sn^t^n, with iukf ur at once with the 
knife "p poiiit, draws its bound aricn. Thus icsfined, it is carofully dia- 
wcteil down, of uniforin tbickiipRs, until the narrow part is reaebed ; 
and thou the incisions aro carried b) a grealer depth, to insure an 
ulnindanet* of vji^ndar supply. In no part of the wound is the peri- 
oraiiium interfered with; and, if |>ossible, the dfip should not be made 
to encroach upon ibe hairy senlji — for obvious reasons. The neck nf 
tbe flnp IB lundc snificicntly long to admit of its being twisted, without 
flcnons inlemip^mn to ihe cirr^nlAJion ; and, 1l> faciJilatH this movement, 
the knife is cariieU lower down on that side to which the (wist is to be 
niiule. A little time fa allowed for tbe oozing of blood to cease ; then 
the liap, having been twisted so as to bring the integument upwards, 
is adjusted lo the rudiments of this old featoreT carefully and iu:curalely, 
by the rcquifcite number of points of interrupted Hntnro ; tmA support 
ia afforded to the flap beneath, by the lodgment of dowilR of lint, so as 
to give that prominence and cLanicter which seem best suited to its 
new office of repair snd imitaiion. The lower part of the wound 
in the forebcid is brought together by sninre, and may unite by the 
firsMnlention ; the rest is covered with walei-djessing, mid left to 
granulate. The flap adharoe, in part by adhesion^ in part by granu- 
Intion ; tliG Htitches are cut away at the ordinary period ; and the in- 
terior stuffing ia changed from time to time — medicated if jieecssary- 
Ultimately — in twelve or fourteen days, usually — tbe borrowed sub- 



I 



REEN0F1^3T1C& 



143 



stance becomes firmly aeated in ite new aliodc ; and then attention la 
directed to the fonnectia^ alip- tf the ossa niisi have lieCD left entire, 
with Ihexr iut^ument, ihe apes and jiIw only bavitig beeti deetrojed, 
the connecliiig tilip iiifiv be divided aod removed. A wedgc-aliAped 





F^. IS. 



Kin. «^ 



portion is tftken away by TCL^aiis of n narrow bistoury ; &nd lidjuetment 
is effected with the integument beneath — made raw ty the knife for 
reception. But if the ossn nasi have been loEt, it is well to Icavg the 
medium of aliachment uninierfcred with ; only securing its incorpora- 
tion with the aubjftccnt surface; fpr, hy ita continued presence, the 
WHiit fif prominence whicli the l^iKS of tht nnsfll boups conld tiot fail 
nthens'iae to produce will be very much compensated. Be&idee, coii- 
tinned nutrition of the transplanted flap ^vill be fully secured, and Its 
shrivelling by atropby may bo in a great measure prevented. If the 
prominence ehould threaten to be excessive, it mny be reduced by 
comproddon suitably npplicd. 

Certain precnntiong are ulffayg to ho attended to in such prof^eed- 
iDgs. As already stated, the Sap sbouU at first seem too Urge ; if 
neatly fitting nt (he lime, it is sure to prove insufficient afterwards. 
Twisting is efl'ucted very gtntly and carefully, lest strangulation ensue. 
Should engorgement occur, relief is to he ohuined for the passively 
congested vessels, by |junctuteft, or by drawiag blood from tbe BtUl 
raw edges. Erysiptlm* nrny aiipervane ; if it does, the transplanted 

fig. 48. Ptan of flap for a new noee, according to tbe ori^noJ Indian naethod ; 

«1umn«i apex, ami bI* b*Ang lOl made al onco. 

FV- 4f). Plan nf dap for ilpvt nos^i, oa muJiJieil lij Mr. Lkton. The apex and lis 
pmvliled far; the columnii tit be Lroaght, BUbAcquotitlf, from the upper Hp^ 



144 RHTNOPLASTICS, 

part nwd rmt be exempted from puncture or inciwoD, if these be 
deemed necessary; for experience declares it to possess at least an 
equal tolerance of ^iich remedial treatment as the original textun^s. 

WUen pecijliiir circuraslaucea render the ordinary operatitm im- 
practii:ahlt?i the flap may be taken from tlie hairy scalp, ofi practised 
by Diefferil^ch ; the hair having b«cn previouBly remov&l by meaos 
of the bithluriJe cf mercury in eolulion; and the flap hein^ connected 
with A hjug narrow strip of the integuments of the forehead. 

When consolidalioii of the new alfe and ajiex las been duly 
effected, fomiaiioii of the col^imna u tticn proceeded with ; according 
to the mcLiiod first prop<<jM?d by Mr, Liston," The centre of tliu upper 
lip is found tumid nnd o!ongattd j in CimBcqucnoe, romovul of a portion 
of the redundancy would of itself be ft confiiderable impmvement ; and 
when the ^wrtion so removed can bo converted to the uticful purfjoae 
of constituling a nioht efli<:ient new columna, tte espedioncy of the 
proceeding l)ecom<'B very apparent. 

*'Tlo umtr Hiirface of ibe ajies is first pared. A flharp-poinled 
bistoury is thou i^aBBcd througli the upper lip — previouBly stretch^ ii[id 
raiscil by an aRsinlant — i-h>Ae to the ruins of Ihe fonuer coliimoa, atid 
about an eighth of an inch on one side of the m<?sial line. The inci- 
sion 18 continued down, in a fitraight direi-'tiorj^ to the free margin of 
the lip ', imd a wiiuilnr one, par.'vlL'l to tiie former, is made on the op- 
posite sMe of the mcsiid Ymv^ si> um to iiisid.ue a Ihip about a quarter 
of an inch in Lreiulth, and couiposed of ekin, mucous membrane^ and 
infer[»nm'd nid»jitsin*7o. The fnemilura is then divided, and the i)rola- 
Iduni of llio flap removed. In order lo lix the new tfohiuma firmly 
and witii accuracy in its proper place, a sewing needle — its head liein^ 
covered with sealiiig-was lo facililale iis inlroduclii"*u — is passed from 
withiuU through [ho apex of Ihe nofic, and obli'iuely through the es- 
trpoiity of the elevated ihip : n few tunia of thrt-ad ever this HufBce to 
approximate and rt>1jiin th^ surface. The flap is not twisted round 
(Lfi in ttie operation already detailed, but simply elevated, so as to do 
away wiih llie risk of faihire. Twitting h here unnecessary ; for the 
mucous lining of the lip, forming the ouler surface of the columiia, 
readily assumes the [dolour ami up]}t?arance of inlegiimeDl, after ex}w- 
auro for mmetinie, n^ is Wf?11 knoMMi. The fixing of iho columna 
haviup been aceoniphsht'd, Iho i-rl^a of iho lip must be neatly brought 
togelher by the twisted auture. Two neeilles will l)e found siifficieat, 
one Wing passed close to the rdge of the lip; and they should be 
inlroilnci'd deeply ihro^igb ils siiljslant* — two-thirds, at least, of its 
tliiekuess being mad« siiperficijil to Ihcm. Should troublesome Weed- 
ing Irtke phice from the coi'onary arli'ry, a needle ie to l>e j>aBfled so as 
lo imndist its exlreraitiea. T)ie :vliiile siirfaee is thus approximated; 
iho vehsels being coni[>re6sed, bleeding is preventeil: and finn union 
(if \\\6 whole wound is secured. The ligature of silk or lineu, vbicb 

• PracUul SurpUT. p. SSL*. 



PARTIAL HESTOIUTION Of TllE NOSE 145 

ia twisted round Lhe needles, should be thick aud waxed; and care 
uMist be taken ihaL it is applied smotiihly. After sotuo turns are made 
round the lower needle» the eEida should be securcil bj a double knot; 
a second tliread is then nsed far tbe other needle, aod likewise secured. 
With the view of comprfssiiig and ouaptaiiug the edj^es of lhe iut^r- 
posed purt of the wound, the thread may by carried from one n4?edle 
to the oiJier, and twisted round then» fleveral limea; but in doing Lhia, 
care tnn^^t he taken not to putl vhcm t^^warda each other, elBe the 
object of iheir ftpplicalion will be frustraled, atid the wound reiiderc^d 
puckered and nneqnal Ijaat of all, the points of the needles are to be 
cnt uff with pliers. No farther dressing is Toquiieil, The needles 
may bo romove<l un the third day ; their oT^db ure cletLued of coagu- 
lated blood, fini\, after being turned gently round on tbeir asis, they 
are cautiimsly witLdrawii without disturbing tbe threadh or the cniat 
which Li3 been formed about tbem by the serous und bloody dis- 
charge, TLis crust often remains attached for some dayii after remov*! 
of the needier; aiid, befiideA forming a bond of unioit, is a good pro- 
tection to the tcndur purta. Some tare is afierwanln required, from 
both Hurgeon and patient, m raising np the alip, by filling them with 
lint — ihua com|iressing llie pillar, eo as to diminish tbe cedematous 
swelling which takea place in it, to a greater or less degree, and re- 
preasiDg the granulations. It ib, besiiles, jieeessary Ui pubh upwards the 
lower part of tbe column, so that it may come hiU> its prosier situation ; 
and this is done by lhe ftpjiliuniion of a sm^ll ri>iind roll of linon, 
anpjmrted by a narrow bandage iiaased over it and secured behind the 
vert€i." 

Partial Restoration of the Nost. 

"When a portion of either ala ie destroyed, the <leficlency may l)e 
readily ^up^ilicd from the adjoiniug cheek ; if there he the ordinary 
fulnesR there. The dap ts raised, EranKplanteil, and has its vascular 
aupply maiTitaiiied, by conducting the operaticn iu the same way us 
for restoration of the whole organ. Tbe wound in the cheek may, 
generally, be approximated cDtirely; and, in con^quence, may be 
expected to unite by the firm inteutjon. 

The entire ala may be restored in a similar w.'iy. But if Ibt- 
cheek he either aaturally spare, or already occupied by cienlrices, the 
flap niusE be brought from the forehead. An operation is perfonnedf 
similar to that for reat^ration of the whole organ, hut en a minor 
scale. When tbe ridge of the nose is long, it is well to make a suitable 
furrow ia ita centre — by incision — fur receptiou of the long connecting 
alip \ wbich, otherwise, findiug itself but indiflcrently supported on the 
CTterior of the na&al integument, might fail to afford due nouriehment 
to the flap, and induce its sphacelation. After union has occurred 
throughout tbe whole wound, the coanectiug slip may be ralBcd irom 
itB temporary licd^ and the raw edges of ilti site approximatftl ; or it 

L 




I'ABTIAL RESTORATIOK OF THK NOSE. 



may lie left undisturbed; according as circiimRUnces may seem foj 
iodic ALe. 

Loes of tho ftiwx and both aim ia siniplicd by ft frimtnl flap ; with ' 
or without lodgTnent oF tlie oonnecting slip, according to tSie length of] 
Ihe nowal ridg-e. 

The rid^ itself, when deficient, may be restored by a frontal flap, 
very readily and efficiently j either by adapting a Bujtalle portion to. 
its Burface, made raw ; or by iuuertiiig 9> slip into a sulcus niade f^r lU ^ 





Fiff, so. 



reception. By cuttinc^ out the depressed portion^ and approximating 
llie margins of tho wound by autnre, depreBsIon may be removed, in 
some cases saiififactorily ; but, in most, such an attempt would be 
rollowed by an clevaltmi of the a|>ex, caiiniig a deformity little less 
uneeoinly than the ori^njil. 

When the cobjmna alone is deficient* the operation for ita restora- 
tion IB porformeii, as Jelailet] at page 142, 

Not unfreipieully, the columnar and ihe inleg^imental part of the 
alff and apex, ren^jiin eiilircT vKile the earliUgiuou^ texture Las suf- 
fered more or U-h?? dihipidatioci ; and tbc noH.^ in conNoquence, ubriiiks, 
Ealls inn'a.rds, and ia uiLich dt^form^d. AutopWty is not required 
to remedy this atne. In some examples it Is snflieleni ti> diridf? care- 
fully the abnormal adhesions within, to eleviite (he nostrils then to 
their norronl level, and to maintain tliia elevfttion Bnbseqnently hy 
wnitable stuffing of the cavities. In other cases^ however, such mani- 
ptiUtioD is found tusuEBcient ; and thL*n it is ex|Tedietit to appnixJiaale 
the checkSf ao os to force th« noee into iDcrcoGcd prominency | th« 

n^- fiO. "The ahe of tlie note, 6e&i.-wnevs in Lhe aijvr. Aa\inim, or Inftral paiU of 
ibe vrgvi, In the fi>r?hefld, &Cr, may be mppUrd fmm thv DPi^hlrirming inlcgiimtnt, nn 
Uu UTn« prim-iplp ii= ihi- pru'wiiny rejfliiw. Tn niAJiv of ihi-^of^pi'rHTimi" On- t\,i|t <<\ii bf 
■o cnniriveil adJ cul 11111^ 05 Ihul El tan \>e applied wiihoiil 'iis aUncbmeut bem^ Lwistcd. 
The form *)l »iich tUpa u here f^hen." — Luton, 



I 




PARTIAL RESTORATION OF THE N09K- 



147 



ori^niil infterliana of tlje al® on the check having been previously 
iletaclied, by mbcu tan eons iiiciaion. Tho i>rgan, thua renduretl mOT- 
ftble, is transfixed at its basa horizontally, by silver needlesT wliieh are 
made to perforate a piece of loatberf or wood, after emerging from the 
nose; and by twisting tie extremities of the needles, oo this exterior 
fnreign siib^tanoe, the due amonnt of approximation is efiecled and 
maintained/ 

When there is botli depression of the alee and apex, and loss of tbc 
coZumna, tlie depresdun is fin^t lo be rein'^vcd; unci then a new 
coltunna ia lo be constructed in the ordinary way, 

Uut, in tnith, no exact details can be eatablUbed for any anto- 
plaatit; or simply TSHtorative operation on thiB orgfln ; tte proceedingw 
must vary, in almost every case, according to its peculiar circnm- 
Btancea. 

It is right fiirthor to state, that the majority of such operfltiona 
come under the L'aiegory of ihoKe of "^cumjdaisance " — undertaken 
under no absolute necessity, but rather to plcaiw tbe patient — prover- 
bially prone to untoward cn^iualties in tbe nftt^r-trealmcnt. The flap 
may ahrink or alough ; ulceration may recur ; eryaipelafl, phlebitis, 
pyicmia, niuy fieri] cxibtence- J^nd, at tLe same EimQ, it is to be 
remembered that it very pfissable substitute for the lost org'au may bo 
adapted by the mechanic, without pain or danger. 

For furtUcr inTonmliirn oa RlimoploAtic, tltc flttidtiiit is rcfum^ to the FrncHcal 
Surgery uf Mr, LUtun, jtoiL Uh writing* of UiciTcoliacli— wbo^ in Iliia dt^partnteaCi bade 
fkh Co rival tba &jiic cted of TftglvcoUodt 




148 




CHAPTER VII. 



AFFECTIONS OF THE SUPERIOR MAXILLA. 

ColUetion of Fluid in thf Antrum. 

The antnun is liable to become tLe seat of a chronit collection of flnid, 
thereby iLs [mrietefl are espanded und attennaled, and its carity much 
enlarged- The condition is ordinarily termed abscess; l>nt it weema 
very dmtblful if Ihis ap|)ellation be accuratt^ly applied. The fluid may 
be purifonn^ Imt is scldura piimlent. It is more like wbrit is usually 
found in serous cysts ; somedmes thin and &er<HiBj fiometimes glairy, 
sometimes santruinoient, sometimes puriform, not unfrcqaently mingled 
witb more or less of solid curdy matter. The pnrietes of tlie cavity 
are not thickened by fresh osseous deposit, as in clirouic abseess; on 
the contrary, Ibuy cire simply eipaiided, Ijecoiuing tliiii, and in eome 
places pt-rLapfl defieiont — Ibo li»sB being pnpplied by tnembranous etruc- 
ture, rnntribiited pmbably by Ibo perinRteiim. Tn short, the morbid 
condition more resembles tbal of osteocystoma, iban that of chronic 
abscess of bono. 

The symptoms are — uneasy sensatian in the part ; swelling of the 
theekj which uUimalely cnickles on prebsure, and may be felt to fluc- 
tuate — Iho pariotes hnving Iktotqo much nttt'iiuatcJ ; the palate may 
bulge coufiiderably downward'^ ; sometimes tliew is increased secretion 
from the corn? bqHin ding- noi*tri] ; und from the hanging and stiffnesB of 
the lip on that side, ariienlulion may be interfered with. TLe change 
may be attributed to a slight and remote injury; or to the presence 
of decayed teetb in the cora^sponding maxilla; but, very frequeutly, 
there is no asi^igaublo eseicin-^ can^c. 

Tbs remedy is by evacuation ; !ind the ajwrtiire miiat be both free 
and dependent. An aperture suiEcienily dependent may be formed in 
the corrcsiJonding alveoli, of the canme or first molar teeth ; and some- 
limcB a communication is found already established there, on removal 
of the decayed teeth or stumps. But sm-b an opening- is seldom if 
ever srifficiently free, when of spontrmcmia fonnation j indeed^ mifGcient 
space is not rcajlily obtained at this part, even by operation. And 
it IB ewcntial that the opening Khali be of some considerable size; 
otherwise the fluid will not escape by it; but will be retained by 
fttmosplieric pressure — as in the case of the narrow-necked bottle, which 




ABSCESS OF THE ANTRUM. 



149 



when filled with water, \s suspeDiled in on inverted position for baro- 
metric purpose*. It is btlter (o make an opening llirongh Ihe most 
di:j>endcol part of the attcniifttcd purielea; above the first molu.ra. The 
meni1>rfLTi6 of tlie cheek U inttsed tliprf ; sind, by moani^ of t\\& Bjune 
infltrument — e, strong bistoury — tlie parielea of tlie eavity may also be 
perforated in tlie gi-eater nmuber of oises. If ilie bone, however, prove 
thick and resisting, a j)oinleii iever^ as use"! for the e:ttraclion of 
decayed teL-th, may be employed. An aperture having been nuide, of 
Hufllicient dimensiona to admit the point of the litllc Sngcr, throug-h 
this the contents readily drain nway. Beeide^, re'Accumidation is 
eftectiially prevented; iind, by pressure from without, return lo the 
normal state by eontruution is favoured. 



Abscess oft/ti Antnitn. 

The lining membrane may uoderg-o inflammation, with or without 
the apjdication of external violence ; and siippuriition may ensue. The 
afieclioD may be eillicr chronic or acute. In the former eyent, the 
case will very much resemble the cystic enlargement just detailed. 
This, however, is of rare occurreuce, and is usually UDCon[iected with 
titenial injury. 

Acute absueKs generally refills fTom violence applied^ or Irom irri- 
tation eummunicaied by decayed teeth or other affections of the gums. 
The fiyinptoms are severe. With a 
considerable amount of cunatitntional 
diaturbance, there are dcep-seiite<l and 
great pain, tonsion and throbbing^ and 
swelling of the superimposed soh parts. 
Ufiually partial evacuation takes [dace, 
Bpoutaneouslvj by the -side of a tooth ; 
with relief from the more prominent 
Bymploms. Such imperfect eracnatioD 
and relief, howtver, are not enough , 
the uperation, above the biouepid teeth, 
afi for emplying the indolent fluid col- 
leclieu, must be bid recourse to. But, 
of cour&e, in the first instance, ntlempla 
are made \f> forego the neceasity of all 
operative interfbrenccT by tiraeoiisly arrebling the inflammatory process, 
if possible^ ore niatttr has at siU Formed. When purulent accumulft- 
lion baa taken place, the flrtifici;il opening cannot lie twi soon esta- 
blished. For From the turgid slate of the membrane, it is ver>' obvioua 
that no partial relief can be expected from spontaneouB evacualiun 
throngli the nasal aperture — as Boraelimes happens in the indolent col- 
leclien of Cuid. 

FJg. 51- EiiUrgeniflDt ortheanuum, by ucvmuLRtioa of UuIlI wUhin. 




lis- 51. 




160 



TDMOURS OF THE BCFEaiOB MAXILLA. 



Poii/pua of the Antriifi, 

The lining membrane uf Ihis cavity, like that of the nostrils, maj 
givo origin to polypous f(jrniulioQ&. But ihe iM?currence uf beiiigii 
polypi bere ia comparatively ntre. The medullary formati(»n xb not 
Tincomraon; constUnting the origin of onteocephaloma, as iLffecting this 
lone ; and amenable to the onHnary niles of traatnicnt. 

Did plttiii iudioations exist of the preaence of o Unign polj-i>u* — 
mucoufi or fibrous — within the antrum, it would certainly be our dniy 
to expose the cavity, by suitable ioeiaion, from the moiith ; with or 
without division of tlie lip; and to eradicate Uie morbid growth 
thoronghlj. Such caMR, however, are extremely rare- 



7\£iiiftura of Uu Superior Max'dla- 
Twu fonns of tumour are liable to occur in this bono ; Oeteoesr- 




tomu jimt tlhteoouphttldma. Ttimours very diffeTunt in themselves, and 
t^'iiuiring very dIflVreut trtuOuimti tlie one early irremmliiible ; Ihe 
ullnjf u*iHihlo of <:uro, nt iin lulvunccd dnte, iind ftAer a lurgw <jr even 
iiiiormona «iKo has been iktlmikriL 

Tho oMmiHun^imui luuy leaeb a hvrjrt* eiKe hy exk-mal hulrring-, and 
by tXimuNion of ihf bono ; l>ul. unless il degenerate in structure, it 

Rtf, W- \Ats,t> IhlnoMrcimin ftf iipppr j»k; mnwrmtd, shewidR tbrcwHou* rtronm. 
9(111 UiuIIihI la tU nuiwrloT iituKlUii, In which il Liri^jinwed.- llowsHir. 



EXTIRPATION OF THE SUPERIOR MAXILLA. 



151 



remdns limiteil witbiu (be ixtiifiucs of the superior maxilla; aud con- 
eeqneutly, l>y ramoval of that bono ulono^ tho whole of tbo dieooseil 
rormatinn may be taken away. The Bwellin^r projects into the ffliiccR, 
into the mouth, and outwards on the cheek ; tho main protiiWacce Is 
ID the laAt named direction, interferiLi^ with articulatioUf mautication, 
and vision ; a thin serous discharge escapes by the mouth, seldom 
bloodV) aud Ewldom (jfieiLsive ; and the gi^neral health uiuj be hale in 
all respects. The remedy is excision of the Gtiperior maxilla; and 
this^ though a eevere and Gomcwhat difficult operation, may be fear- 
lessly undertaken, ev(^n in the moat advanced ciia^s of thia dUease — if 
genuine ; experience having proved that the isaue of sacli operations 
is almost invariahly pro»i>erou3. 

The otitcocuplaluDui may be uf oriyinal fnmifttioit, or luaj be Ibo 
Tesxilt of OBtf-osarooma degenerated. Wh«n of Ih^ former character, 
the diseased formatioa has extended beyond the limits of the superior 
maxilla, ere any considerable prominence has appeared externally. 
The outward lumour may be yet triflingf while the mouth and fauces 
are completely occupied, and tlie base of the cranium hopelessly in- 
volved. The fsystem, too, is already worn by ujaligLiiuit hetlic. In 
euch cases, ac cannot — by cscision of the superior ma-xilla, ihe piilatiim 
bonefi, aad the malar — hope to take away the whole of the tumour; a 
portion remains, deep-seated and inaceeseible ; from this, reproduc- 
tion of a tumour, soft, fung4.ted and hlceding, Lakes place ; and a most 
disastrous i^u^ue is precipitated. Or, not improbably, the already much 
eufeebled Byatem hpeedily siidtfl under iho Jmiuediato effecta of the 
operation, ere ever a new production ban had timo to form. In short, 
while we may perform eJtcUion of the upper jaw with th& best prospect 
of success, even at a late period of the case, in osteosarcoma; we 
ought to refrain from operation in all ejamples of osteocephaloma, 
excepting those iu which wc are satisfied that the disease is yet recent, 
and limited to the bune in which it itegan — and anch cases nrc very 



Extirpatitm of the Superior Masilltr. 

The patient is seated firmly on a chair, or reclines <in a table with 
the bead and shoulders considerably elevated ; for so the ma&ipula- 
tions of tbe surgeon are fucilitatcil, ai^id the ontward escape of blood t? 
favoured. As elsuwhero statod, my own improssiun is, that ancQsthofiia 
by chloroform is at least of doubtful propriety here. The csperience 
of others, however, among whom I may placo the high authority of 
Mr, Lawrence, testifies that this important ageut may be employed, 
imder due precauiiou, eren here with perfect safety. If usetl, every 
care must be taken to prevent the m^iin risk, namely, asphy^u by ac- 
camulation of blood in the air passage. 

The jaw having been made clear of teeth at the point where section 
is intended to be made, a strong bistoury is inserted near the inner 




162 



KXTIRPATION OF THE SUPEBIOH WAXILLA, 



flornor of the eye, over the nasal v"m^ss of the flui>enor maxilla, and 
iK Inuight clown k. tht mcutb ; cnllins: the IJp in tbe mesial line, and 
dlw<oolin^v ihP alft of the ni>stf from ilH \jaais, Tlio knife is ogain en- 
U*ml ifvt'r llic t'ltlcrnttl ftugnUr proi-^^ii^ i>f ibe fKintnl lM^nL^ mnJ (^nmed 
iddlt^Klv aowhwonls to liie wi-le of llie nioulh ; dividing the whole 
l\xk\n^^ of son rarU, The flap iiidicaled hy theae two mcisions, 




is then ilii-iWcti.H.1 npwai-ds v^fT the tumour^ and is hdd raiaed by an 

assislftiU, The orliiml cunleiils nre stparated from the bone, on iheir 

Kiw'cr n,H|uH'l ; hihI nri' f^iitly cU-v^ili^d and protected b_v u tiat copper 

sptiiula^ wUioh if* nlso rol^i[W hy Ihe iisjiistant. The soft palate is 

i)ioi^<'d in tlie itiesi^il liius i-orri'5i>oiidin^ly ^^ith the woimd of the lip; 

Mul, by i-ross cntting, llie i>enduWis velum of the palate i8 scparmled 

fmm Ihfl diw^iuetl pnrts — now i&dated, so fur as ihe soft lostures 

aro eaiK'onu'd. By a small n4h — slroii^-r and longer tlian what is 

oi^liiiioHy sdd nff Mvy's — tho union bclween ihe raftxillar ami malar 

Kino iti »i'Vitrt>c|, lly tho ^m^' itiT^lnim^nl the alvei^lar proeebs is cnt 

(hroinrh, at tlie part e^iH^sed by the labial wound ; and a groove is 

»]ho inmle in llie imUiine pnn^o-sfs at the part Incised. A {AJTi^eLout 

And lon^ Innie-pliors may ihen Ite used lo complete Ihe section al this 

^mrl ; oni> hiaili* ro^lin^ in ihv pulatine and alvenlar gTiX»ve, tbe oilier 

pnstud ihio thp evrrce^^omliiip iiusiril, If snch nn inslnuntnt be uot 

al hinui, liouevor^ rhc woiinn inay be completed readily enough 

by tiununt of tin* wiw aloiio. The nasal process is severed by the 

oixlinary cutting plii^re. Ami now. by prefisin^ the tumour down- 

wanla il is dislixlg;cd from iLs connexions; while complete separation 

10 readily eftecled by tunchiiig Hilh the knife those soft parts which 

Twpnrr its cd^P. The Tcluni i>f the palate, formerly ^paxaled, is care- 

Tig. bS. Tqmnnr r4 th* u|ijPeL- j-w ; thrwlag ibr Uih» .if IndrOnH ftn nmoT»L 




EXTlnFATlON OF TDE SUFEKIOR HAXILLA. 



153 



fully prener^ed — and, if poeeible, also the |haIaUno plate of the |.iftlate 
boLG. One i>r two vphsel^^i bunging in tlie A^m n'ound, will proLaLly 
reijiiire lig-nture; and ibe facial veesels, wlich during I lie openition 
wi'TO rcAtraitied by the fingers of an astJBtant, are also Becared, The 




Bmoiint of deep bleeding is often but slight ; tlio vessels being tom, 
not i-ut, during evulmon of the tumour. Tlie vacant Rpace, having 
been cleared of coagnluniT is filled with lint; and over ihia the flap 
is replaced. Both incisions are then brought together with great 
BCCuracy^T \)f means of ibe twisted and iiitemipted forms of suture ] 
treatoient is conducted for ftdhesion ; and, generally^ this does not fail 
to occur, in almost the entire extent of the faciid wound. The deep 
cavity iif couTHt? inflamefl and srippurates. The lint loosjcne, and is 
brought away* A less amount of dressing is daily renewed, medicated 
with a weak solution of the chloridea; ^anuiation advances, and 
cicatrisation is in due lime obtained. In some cases, a marked defi- 
ciency remnine ; and thin TOAy bo remedied by tbe ekill of the dentist. 
But in other cases, the deficiency is wonderfully atoned for, by Nature's 
effort alone; partly liy the formftlion of new matter, [wiTtly by con - 
tiacliou and accommodation of the old. 

Wben the tumour is of large size, the malar bone is encroached 
uporif and has to be tukcii away along with the maxilla, lu such a 
oftHc, a third incision ia made along the zygoma, terminating ia the 

K3f;. 0*. PurtmJt atttr n'timvul nC thi- u|tjH?r jiw, Hir <>-rBionrv<>miL An cxanipU' Cif 
how little deffkrmlty nmy la mnoe cava Twaaia. 



n 



J 




EXTIRPATION OF THB SUFEUIOB MAXULA. 

.„p. part of tut wy.h P--s:;^:-22i^:^^^ 

the angle i>r l^ie njimi^Ji|»^ ' ^ 

divided by tbe b(i^^^^^*^ Hmnll, one iiicifilon mflv sijffice — tlint from i^iTrr 
If tlMip-*'^^of the uye to tlie angle of the mouth ; it "being quite pua- 
-iJte tu exfKise the parts sufficiently, by raising the triangular fl/ip 
while the lip anti front-face are reu^ned entire, 

Dieffenbach'a mwle of proeeduro is as follows : — Having made the 
centrn-l in*;i8lon by tho side of the noscj the knife h carried acroBS 
beneath the oyo to the temple; mid the flftp thus iodicfited ie diKgecied 
off. This admits of a thorough expoBurc of the tumour; Bubsequent 
deformity by the cicatrix is comparatively slight ; and paralysis from 
divisioD of Iht! facial nervts will probahly be avoided, 

If itny doubt should occur to the mirgcuu as to the eolidJty of the 
growth, nn exploratory puncture ahuulJ be made in the diTeclioo of 
the antnimT previous to o^>eralion- For, ejtmion of the upjier ja^v Js 
rather too severi} a rtmedy in tho cose of mere dlstenBioa of the 
antrum by aecutnulation of fiiud. 



See Uibliiigraphy uf PlsefiMfl of Banes in rrindples of Surgery ; alaoUuTH, Lonflon 
N^ical (riiTL^tti-, vaI, t. [*. *t-2\ nnd Sy-^ieni of AnaUiniitAl riali"*, parf ix, Dlin. 1S2G 

Ue Puiis vol. U. ISH. (iutlirie, Mi-diial GitaelU.', vol. xvii, 18^5. O'thfliiyhmssy on 
Dii'Cfi.it'.s at llm Jnws, Ac, Cfllcuflii, 18J4. Listdii'a J'raiiSca] SurjiTcrv, la.^t cdiiu>ri- 
LUtoa on Tuuionra i^f Uiu face, Mt'il. Chir. Tnuifl, vol xi- Dii-Jl'pnlMich's (JperMlivv 
Siirgirry, Lcipaic, 1B48. MecliuJ Times, 24tlL Uav ]»15| . 



155 



CHAPTER VHL 

AFFECTIONS OF THE FACE. 

WoiTSDft of tb« face are apt U> bltcd freely, wd usimlly n*<|nir<i 
iHJgatiOQ of ibc vesst'ls. Coaplalion c^huiild bo most oinfiilly oflrciiul, 
and ocUieKiou i:iiurtcd, in oriler lu ttvuid dt^iomniy bj lUiitiJ/utiim, Hft 
ranch as poaeible. TraiiBV4>rbC woniida may iiitorfuru nn|j[i<abiiiilly with 
Lhe purotid duct ; and, by division o( thu braiicliL^s of thu |>ortlo 
diir%, may pAralyze th(^ cheek, at l^ast for a timLi. AflL'riMoiilri/.alion, 
resumpUoQ of the ucrvoua fuaction may bo uxiHidiUd by friotiou. 



WjLTtfi not unfroqnently form nit tlio inte^imi-nt of [hu faoo- Tlioy 
sbtiiiM nut be alluwod to ri^niaiu: fi>r, by ihn tiiiiu old a^o Iilla mi}«r- 
TCDed, they wlW be found either alrt'ady de^^uncriitcd, nv proiui U> 
become so. It is well to remove them curly by the ordiii^y lucuns 
nrhile ihey &re yet lumple, 

EryaipeJas seldom afsuiiies ihu phlt-gmonoiiR forni in the fjiee. 
PuDctures, consequently, Kuffice for abatractinn of Idood, and rtliof of 
teoDon- Tbtjy may ba miide freely ; for tho uicalrieea leave no un- 
seemly trace. AflCT Jituippearanee of tbe main iittaek^ tlko jMilient 
must bo cortsfully sviktchcd fur eomc days; rcaC4;c»sion, vrith seei>ndary 
absceas, being very apt to occur in the areolar lissue of the lower 
eyelids. As in erysipdas of the scalp, cold, and other repellent appli< 
caUoue, should never bo employed. 



Spasrafjdic twitching of the muscles on ono sidp of llie faco— tho 
orbicularis oculi, the levators and retracttjrs of the upper lip, and tho 
uorreHponrling movers of the nose — ib an impleasant a^ectloD of no 
uneomtnou occurrence. Often it will yield lo general treatment; more 
etjpecially Lo recLiBcatiun of the prima: vi^. Sometimes, also, pnlJent 



I 



L 



1.56 NEOItAT-GTA OP THE FACE. 

counter- irritation ia of iise^ directly over the piirl ; and prfibftbly Uie 
preferable Diode of applying tliin, is by rubbing on nilriite of silver in 
snbstance, bo he to vesicatti. In chronic uiid obslinuio cakcf, tenotomy 
hfts been had recourse to.* In otio cacLmiile, pcrramient cnre followed 
subeutatn?oua diviaion of the zygooiaticij the levator aognli oris, a por- 
tion of the orliiculartH ocnli, and the deprespor ale nasi. In order to 
restrain hemorrhage^ and conwquent ecchyniosis, liktly to result from 
sncb a croas wi'unj of the face, accurate pregRurc is necessary imme- 
difttely after withdrawal of the knife, 

Neurfilffia. 

Neuralgia affecting the branches of the ftfth pair of nervea is 
tenne<l Tic Dulourpux : at once, un fortunately, ljug of ihe uinst distrese- 
ing and moat nnn]anao;eable uffeclions lo wlilch the human frame is 
liabli;. TLi! Irf^iitiai^iit h siippnsed In fall vsithin the pecnlinr province 
of the physician ; and cfmsiJitfl in carrying mil ihe g<!neral printiplyB on 
which ihe niana^rcmeDt i>f Tif'Tiral;:n:i in or^linarily condivteil. At one 
tirao the snr^'eon'p aid was inil nnfreijucntly called upon ; division of 
ihe trunk of the nffect(^d nerve being stijipiisod likely to afford at lea^t 
an alleviation of the diBlressinf^ Hvin[itoii:a. Esj*riL?nce iias proved, 
however, that such an operation in in uimt cases inexpedient^ the 
relief, if any, ik bnt parliJil and temporury ; and the neuroniatoue 
onlargvmeulH, which form on the truncated exti'cniities of the nerve, 
are likely to prodnce ulEimnle a^^ravatiun. The opendion, in truth, 
may be the means of converting an ex-anjple of netiralgin, nnconnccted 
with sSmctural change, in any port of the nerve, into a worse form, 
de|>eTideMt cm Hlrncmral ehanfre, nol only considerable but probably 
irremediable, Somelinit's the operalior hnn proved sMcccspfid upon 
one nerve, only tfi drive the nennil^ia to anolhfr — perhaps iiiftccefi- 
fiible. Very fieldoni does it effect a complete core, 

Titmnurs uf ihe Cheek. 

Tumours form in fn^nt iif tlie tar, and are of variatis kinds. They 
may he ^mple, finty, fihrotie, or cyatie. CalcartoUH formations, too, 
are not nnfrcquc'iit : ihe earthy mutter bein^ deposited in the stroma 
of a chronically enlarged lymphatic -^land. In removing buch growths 
by (he knife, the greatest faulion shmdd giiide the movements of tho 
hand ; le^ft tlie brandies of the poriio dura be cut acruss, aiid paralysis 
of the check ensnej find Itst by division of th« panjlid duct, salivary 
fistnlfl bt established. In order to meet snch indications^ thu dij^eftion 
fiiiould be proceeded with in the directinn of the emlan^rt-d parts — 
horizon I id ly ; cimlravening the general ndeof cutting in the direction 
of Huhjaeent miiBciilar fibre, 

' DjErpBMiiACH oa Diviaion ufTeiiiluiu and MowIm, Berlin, 1S41, p. 3lfi. 



BIVCSOP THK CHEEK. 



157 



Tutntmrg of tke par^>tid am na^ faOnaidj. For tin ^aad « 
BO siloated AS to render extiqitttioii of it, caCiRt, evca in Um 1kc«lAj 
Elate, an operatioD of extreme difficahf. If it be the nte of ft beiugn 
taiuunr, of n<7 grcvi sizr t>r dnntiau, icavrm] nwj be atleapfed- 1^ 
duEection will b« d««p &bd difievll; andt &fter everr care, » portioD 
oF tlie morbid structure is likely to be 1e& be^ii&d ; bat h is quite poe- 
able that reprudiicdoQ mar not occur. Malignant fomuuioas, how- 
ever, are unifonalj kl alone ; for in iheir cawe reprodiiction is certain, 
if any portion of the on^nal growth, hoverer sUght, be penniited to 
nmAiu. 

Tumourt orvr the panAid an eomparatiTelj (reqiMUt. Ther dia- 
place tbe subjacent gland, came it to fthrinlc bv abaorpiion^ and occupy 
its place. Their extirpation can be effected both readily and safely. 

Sima ofthf Chetk. 

Paticnte fr^nently pre>*cnt themstlTea nnd^r the folIoKing circnm- 
slances. They are adulesceotH, or recently adiih : and are mure (re- 
qnently feoiale tbaa male. Hany months previously, a phlegmon 
formed on the loirer part of the cheek, over the body of the lower 
jiw; Bnppuration took place; copious di?icbarg« baa coittinued ever 
since ; and Ihougb many and various remedial means have been em- 
ployed, cicatrizauon, or cv^rn marlceil ameDdmcnl, haa ne^'cr been 
obtained. There i* a weak simioiis ulc*r, uith a poutiog external 
surface \ and tbe EurruGnding integnmenta are swollen and discoloured 
by passive coagestinn ; ur there is a puckered and retracted attempt 
at a cicatrix, from which matter more or less copioiLsly escapes. In 
tbe great majorily of such cafics, if not in alU the exciting and retain- 
ing cause \a to be found within tbe mouth. Opposite, or nearly 
oppoaite the nfFecIion of the rheeh, a dfcaypd t^vith or stomp will be 
fonnd, probably imbedded in a diseaseii ^im. Aud on removal of 
this — and not nntil then — will the Einus and ulcer be brought to heal. 
Without extraction of the offending tooth or teeth, the most energetic 
and sustained practice may be put in fierce avniDst the cheek, without 
eiLC4:eHH' After extraotioni hejiling may occur wen without any rcmodiol 
means having been applied directly to the part. 

In Gonseqticnce of woond or nicer, the duct of the parotid gland 
may open txlernally on ihe checlc. And by outward diaeharge through 
Hie Gatuloua cperturo, not only are deformity and inconvenience occa- 
tdoued, but uhio a seriona loss is anslained of secretion very valuuble in 
the proceaaes of mastication and digestion, Tbe principles on which 
a cure is to be nllerapted are very simple \ namely, the ealaliiishment 
of an internal oftening, by which the saliva may be poured into the 





FHACTTTRE OF THE HAT.A.R BOTfR. 

month, and sKved ; and the shtitting tip of the external nppHure 
Aviience ^his fluid has previously n:o to waale. A puncture is niado 
lliroHgli the mncouH monibrane, communicating with the ihifl*8 cavity; 
anrl the permaiiency of this new passa^ is aecnredj by the Itxlginerit 
r»f a suitable foreign BubHtonce — either left there fur some daya, or 
introduced at fretjiipiit iiit^rvnls. The external Aperture, liaviiigbeen 
made raw in its edges, is shut by means of a point of twisted suture. 
Adhesion may t^ike place ; if not, Huljsequeiit contraction is induced hy 
tlie applicalion of a heated wire, at long intervals. Autoplasty may 
he of use, ill those cases in which there is much loss of suhsiaoce, and 
in whicli the ordinary means of effecting closure Lava failed. 

Fracture of the Malar Bont. 

This accident ia rare. The deformity is considerable, and unfortn- 
nately not easily remedied; as in the followiug example: — A lad, 
ftg^d eighteen, wsks struck on the face by a full blow from the fiat of n 
heavy iithlpticr luau. The zygoma had given wny, Jind »l>io tlie nuion 
between the malar bone and Jiuperior niaxilla. The former hone had 
"been driven much duwn, givingp a remarkably Bunk ii|>j>eararce to the 
face, with deficiency of orbital margin. By eraraination from the 
mouthy it was also apparent that the roof of tlio masillary antmni had 
been broken and depreswd. In addition to tiic deformity, tlit patient 
complnined of inTit^h pnin ; thire wnK a niiiEihiie!>>s nl lha.t aide of the 

mouth; and considerable dilTiculty was experienced in attempting to 
close the jan', the redundant soft parts of the cheek lodging between 
the toeth. By pushing npwards with the fitiger-pmnls, i:i sin uated from 
behind, the mnlpasition of parts was in some degree rectified ; but still 
considerable dispLicement aud defurmity remained. 

Itu Frictures par Cfntn-onap clu In Mafboira Superieure, I'mris, 18311. 




160 



CHAPTER IX 



AFFECTIONS OF THE LIPS, 



HartUp. 

Tiiii term ib applied to congenital fisBure of the lip; the part, so 
deformed, being Bii|i[K)sed to faftve a rcHemLlatice to tlie Dfttaral dovclop- 
meni of the hare. In genenil, lliero ia a Htroug- wish, on tim part of 
the pareiils and friends, ti> trace the untoward result at hirth to some 
«imBter improRhion mnde on tlie mind of the mother dnring uJt^ntgpHtji- 
tioD — with what success it were more curiooH than (isefid to inqdre. 
The affection may lie single or di>nljle, flimple or complicated. 

Sij\gU Harelip Coneista of a fitaur*?, txti^nding through the whole 
thiekneas of the Itp, naiially tdtiiale on one aide of llie mesial line, and 
either partially rlividiag- the lip, or extending compliilely intti the 
cavily of the nostril. WhyH tho afiWiion is U-th Hiitipk arni smg-le, 
there is no other deformity in the mouth ; the haid and soft palates 
are eulire and fully developed, aod the gums ate normal. Deformity 
ia great, however, even in the «impk:st form ; and the fimctiona of the 
parts are also much interfered with. The only rt-medy in by npera- 
lion ; making^ raw the edges by h^ctsion, approximating the fiHsure 
accurately at every point, and necuntig nriioc by aclh^^sion. The pre- 
ferable period for performing this operation, probably, ia after the child 
hae passed the second year/ By this time the trying process of den- 
tition has uHUally gone by; and there ia cmisequcntly abetter tolerance 
of pain and loss of blood than at an earlier ]icriud. Also, at Ihlfl age, 
the patient, thongh nnmly to ita utnioat» is yet easily taanaged and 
eontn'>llyd ; and the prot-^dxire ia manify^tly fftVOurftbl<» to the due 
advancement of articulation, and the important educational results 
which follow thereon. Yoc a like reaeon as in extirpaiiou of the upper 
jaw, anesthesia is here &imewhat liazardoua; jet, with care, it may 
be employed safely enough — the patient's posilion being altered, occa- 
siannlly, fiu as to obvjEitc the H^k irf choking by blok>d. The child, 
rolled firmly up in a liaon shoe! — nnammj-wise — with itp arms by ita 
side, iR held on the lap of a nurse or an ofieistant, and liiis its heatl 
secured between the knees of the t^urgeon, who ia seated on a chair in 

* The operAlionhaA brcii Hu^ceaafullf perfonned, evMn boon nttet lurdi &Aaiitiau'A 

Rotawiwd, vol. v- p, M9. 



J 



l&) 



UAllKLll'. 




front of the patient &Bd nurse. The free margin of Fhc lip^ on oaa aide 
of the fissurej is taken bold of by ihe finger and tlinmb, aiid put on tbe 
Hlretch, A narrow and straight sharp-poinled bistoury ie then inserted at 

the upiicr uT EiaFiul mig'li; uf tliu il^'Gijienc;y, oiid carried 
BteadiW downwanis, after IraiiEfixioiLT bo as to leave a 
smooth cut fiurfuce on the fi&aure'fi margin. The lite 
lEf done on the nfipusite side. But in neither o^m is 
tlie section made complete. Near the prolabiiim the 
knife is arrested and withdrawn, and the twotiaps are 
Fiig. fifi. ji^^Y pemleiit. The lip is leuipiranly brought tof,'ether, 

and iLn efitimalo ib mado of how miicrh nf the lower part of these Baps 
should he retained, in order Lo Gil up completely the notch which 
is othcrwiKc kj apt to remain at llie prulaLium ; and, this having 
been ascertained, the iie(;esBiLry abbrevia- 
tion of the pendent flaps is made by knife 
OT HcUaors, The wound is then finnllj 
closed, accnrfltclvj by j^ointe of twittiid 
suture^ in the fsame way as in the operation 
for restoring the colnmna naiji. For thia 
modificntion of the operation, in order lo 
obviate the prolabial notch^ we are indebted 
to M. Matgaigne. If a [wuting redundancy 
should he fi>uiid, afic^r eieatrizatioDf it may easily bs reduced to the 
proper outliEie, by knife L>r Beissora if n^ed be; bm, in general, 
absorption will reader all secondary interference unnecessary- 

To aeaist the needles in their work of coaptation, pressure may be 
made on eat^b cheek, bulging the lip forward, by means of a kind of 
truss nnide for the purpose. Some surgeons, indeed, trust to this solely, 
after the inoitjione. 




Fifl.Ea. 





In dt'uhlf^ harelip^ there ie a fianire extending from each nosdil, oad 

Vig. Gfi. MoJgaJgiie'B (fpcrclion, Ilie doUed tinea mask Hie tiaaorr. 

Ftg. 57. Simple harelip. Tbe (iolted Unts mark the mciniunii, u in the ordinary 

Fiff- M. Single operarion for doutie hiielip. The cIoHhI liniu mark tlw Liiciiiuim. as 
OTdinarily t^racli'^L. 



1 



ULCEBS OF THE L[P8. 161 

usually complete. The mlermciliato portion of lip may bo fullj' 
develcjpeti, or it may b© short and deficipnt. In the one ofts^e^ two liriea 
of wound are necesaary — the ordinary operation being applied to eaob 
fissure ; ia the other, a single appro?dmatiL>n will suffice — ns is sufii- 
ciently dlustrated in the diagram (Fig. 58), 

Complicated Harelip, — ConiplifiiUun itttenda on tbe Jonblu form 
moro frequently than oa the aingle. The bftrd and soft pulatcB may 
bfi nleft. Or the gum is in an abnonual state; projecting forwards 
between tha fiasurcs, Bometimes adherent to tLo apei of tlie nose, and 
preeenting feetb growing viciously. The abnonnul slate of the palate 
makes no difference in the operation on the lip ; except to esjiedite its 
performance, m the hope that Ihe ttacdon bo exentd may have some 
good cflfbct, in favmiring diaiinntiijn of the palutinc t^hosm during pro- 
grewrive devolopmont of llie parts. In the case of projecting gum, it 
ia usually expedient to begin the operation by removing the faulty 
part, on a level with the normal gum, by means of bone-pliers; and 
then to complete the procedure in the ordinary way. Id some few 
cases, repression of the prominence may be effected, by adapting a 
sprioged inntnimont calculated to exert the nec^Bf^ry amount of 
proBEiire, 

Ulcere of the Lip». 

The lipe are liable to ulceration of the ordinary kind ; induced by 
exposure to weather, irritation of tartar or decayed teeth, gastric 
diflijrder, external injury, or direct ftpplication of an irritant cause. 
The prelabiutn \ti the part mo&t frt-ijutully involved. 

TreatnienI is begim bj removal of the cause, when that is appa- 
rent; avoiding at mosphenc esposure, subduing excitement caused by 
external injury, removing eoiyces of irritation from the gums, discon- 
tinuiug the habitual use of a short pipe, correcting the digestJ\'D organs, 
&c. Then applications are made to the mre, according aa lis appear- 
ajice may atom to require; and nitrate of silver, either in eubf-tancc 
or in solution, is found to bo the application most generally useful — 
the ulcer usually partaking more or less of the irritable character, 
ThroDghout the treatment, it is of great importance to secure rest of 
the pare ae much as possible. In the child of strumous habit, ulcera- 
tion of the prolabiiim and lining of the upper lip, near lit c^jutrc, is 
very apt to occur, witli much swelling of [he part ; and in sneh cases 
the binding of a riband tightly over the lip Is found to be very bene- 
ficial — securing comparative rest of the part, and promoting discussion 
of the swelling by pressure. 

Malignar^t Ulcers of the lips are unfortunately by no means rare ; 
but are peculiar to the advanced in years, a^ cancer nsuallj is^ and 
the lower li]i is muob more frequently affected than the npper. The 
disease may commence by carcinomatous formation of a warty cba- 
racter, or may exhibit at once the condition of cancer. The most 

H 



162 



OANCKR OF THE LlF. 



oommon inducing oansc ia tbc h&bit of amokin^ ^ilh a »hoTt claj pipe ; 
whicb bet.'iimes hnt, unci irrilixtes the ptulflbiiinii — daily, or mftny timea 
a day. The crnly remedy is l»y free anj eiirly removal of tS:e difieased 
part; ■wliile the disease is yet liiuiled, and no involvement of the lym- 
phatics is apparent. For euperfifLil, suspiciouH sores^ afl'ccling the 
mere pi-olubuim, esebarotics may snffice; Ditrlc acid, nilrale of mer- 




cHry^ chloride of zinc, or [H)taa&a fusa— frutly applied. But when 
other lexturca arc iiivolv^ed, tho kniiti nlonij ie worthy of confidence, 

WLi?n the Hflecticm is Toainly on the snrfacG nf the lip, tKe whole 
miiy he taken away, and yet w'lih very Utile deformity, lly two ellip- 
tical incisions, the diseased epace is mcluded ; the knife being entered 
in the middle of the prolabial space, and made to pass first on the 
integumcntAl, and then on the mneoiis aspect 
of the diatflfle. Tho luurbid Htmcturc, thus 
marked, is carefully diKEectcd mit ; and then 
the saved integmiient and mncons membrane are brought together by 
jioints of interrupted snture. 

When the di^eape is mure extensivej and the lip lax, it is yet pos- 
sible both to remove the diseased part sariafactorily, and to prevent 
any great defortnity. The including incifliouH are made in the form of 
ttie letter V, the appT pointing dowDwards ; nnd nilh oaro taken that 
the good general rule U not transgressed, cf taking away a border of 

Ft?. 50. Cancer of the lip. The ilUeoae (oo ^tenilve For Any oonflervativn cpcriiMon. 



UESTORATIOV OF THX LIP- 



163 



apparently aoiind lextnre along witb tlie truly carcmomatoiis fonnalion. 
The wound is approximated and seemed, by twLsttU buturi^ ; lu^ for 
harelip, 

!□ not a few cases, however, dniosl the wLole ^iirfwe of t!ie lip is 
involved, Ifie diseasG at the SJime time extending deeply towards the 
chin. Under sucfa eircumstJincoa, we have but one paramount indica- 
tion to folfil ; namely^ complete escision of the diBcased part ; and Ihiw 
is a nt:omproTni singly effected by a frue sweep cff the knife. Approxi- 
mation IB not attempted. Eut tbo part is left to graniiliite and heid, us 
ordinary siippuraling wounds do. And tiotaetinieji Ibe liltiinnte d(ifit:i- 
ency of lip, after such an nperatioa, proves much less than might have 
been anticipated; partly on aocount of formation of new matter, but 
m&inly by resilienec and centripetal movement of Ihe old textures. 

The lower Up, vrhen destroyed by carcinoma, may sometimea be 
roBtured in groat measure by ineiflion and elevation of tlie tuljnoent 
parts, without transplantation of flaps; as has been practised by 
Blasias, Dieffeabach, Serre, Syme, Lawrence, and others,* The ope- 
ration is thus described by Mr. Syme, in a case in wliich removal of 
the cancer and reHtoratinn of the lip was done at the same time : — 
" Two inoifiionH were iDude from the angles of the mouth, ko aa to 
moot at the cliin, and remove the wIioIg of the morbid part in a tri- 
an^ilar form. The linea ah and be being auppoBed to repreueut these 
incisions, I cut from the point b outwards and downwards, on each 
side, to d and «, in a straight direction, and then, with a blight curve 





F\t *o. 



i^-*i- 



outwards and npwarda, to/ and g. The flaps abdf and cheg were 
next detached from their subjacent connexione, and raised upwards, 
BO that the edges a h and c d came into a horizontal line ; while tbii6e 
represented by 5 <f and he met together in a vertical direction, and the 
lateral exlenfiinnn to / and g allowed siifficitnt froe^loni to prevent 
any puckering or owrstraiaing. The respective surfaces were lastly 
retained in contact by the twisted and interrupted suture ; four points 
of the former being inserted ia the middle line from the lip downwards, 

• a* Bladiiia, Klinbcluin Zuilaehrirt, Rjd^ 1S3G- Dicfft-nUach, HindlmcIjderF'liis- 
Ut:hen ChirurKi*!* Ucrlifi, 183S. Sfire, Traite hur I'Art dt RcaLiurtr Ics Ddutraitea dc la 
Fa»j Pnriii, 1813, Syviw, Monlhlf Joonul, Harch 1S4T, p, 643. 



1 G4 CHEILOPLASnCS, 

&nd the Mcie nnraber of the Utf*r in the cmred portion on each side. 
Tlie wound tbcD prcaenteii the appearance shewn by Fig. GU II 
healed entirely by the first intenlion." 

Ciincnim Oris. 

Thta U fto example of Slouching Phagedena. It origiaatefi in the 

mucoiis cicrabrane of the lip or cheek, and exteode sotnetimeB both 
rapidly and far, presenting' the usual cbaraclera of that class of sore. 
It is almost exclusively met with in the ill-fed, ill-clothed, and iU- 
honeed children of tbc poor, in densely populated towns. But in any 
chiy of weakly habit it may be induced, by irapnidetit merctirinlism. 
The constitution s.yTTi pal Kinoes gp'patly ; In the fonn of iiriljitive fever, 
lending to the typhoid character. Treahnent consists in amending the 
outward condition of the patient, if possible, by change of air, ventila- 
tion, &c. ; rectifying the priiofe via:, by studiously avniding all mer- 
curial medicines; carrring out the active local treatment suitable to 
thiB form of eore ; and administering internally Ujc chlorate of potJifiS 
— found to be a very appropriate alterative, in the dose uf from one 
scruple to two hcmpleB in the course of twelve hours. In the worst 
form, nourialiment, Ionics, and even stimuli may be imperiously de- 
manded, to prevent sicking. And if the patient survive, the loss of 
EubEtancc will probably be such as can be remedied only by a detenniiied 
au topi antic operation. 

When the lip has been lo.st, either entirely, or in its greater part, 
in a patient otherwise of tolerable health, anJ not far mlvanced years, 
restoration by autoplasty may be contemplated. The part may have 
hecn destroytd by wuaiid, uloughiiig, or iuiraetahle ulcenttion. Li 
the last mentioQed case, we must be very careful not to attempt the 
engrafting of a sulistitnte, nntil all ulcerative tendency has for some 
lime wholly ceased— for very obvious reasonM, After removal of tndy 
cancerouB disease, restorative interference is seldom expedient; unless 
by the peculiar arrangement of incision already sj)oken of. 

The autoplasiic operation is conducted on the same principles as 
for restoration of the jiokp. A flap, of snitablo form und dimenfiiona, 
is hrought from beneath the chin. A connecting slip is left at the 
aymphysis ; there gentle twisting is made, so as to bring integument to 
the surface ; the port is secured in its new site hy Eulurc ; and, by the 
like means, a [xirtion of the Biibmenlal wound is approximated — the 
rest being left to heal by granulatii^u. After adhesion of the flap ia 
completed, the mental liUp of attuchmerit b divided, and smoothed 
down, hy the bistoury- 

Sm DiofTiiiibAch, ^c, aa in Iht iDotitolo of t\it- formtr psgO. Vlp>al Sur- 

gery- On Cfnf-nini Orifl, ^f llnnbull Hnll, Laui'pt. ISSfM ' 4f PrAct. 

Surgery, fiu6t>ocff^ Haul, ^\cd. Cbir. IVoaa, vol. iesvI- > p. Go. 



• 



165 



CHAPTER X. 



AFFECTIONS OF THE PALATE- 



Congtnkal Deficienry. 

Extensive deficiency of tlie hard palate ia with diffinJty remedialle. 
Miiigation of tlie deforiQity and inci>nveniencu may be eflecied by lUe 
dentiflt ; (I meullic plute being fitW into the ckiHiu, on coraplelion of 
the part's deuelopment. Also, sometUng Tuny be done l>y surgery ; 
84 recommended by Dr. J, M» Warri-o- The soft parts, having been 
carefully disstclcd off the bony arch, aro brought loj^'elher by suture, 
after the edges of tlie gap have beeti made raw. What filled the arch 
vill probably meet readily on a plane siirfucc; but Hlioiild difficulty 
be eipenencccl, further rclasatic^n may be obtained by dividing the 
anterior pill are of the eoft velum.* 

A mere fissure of the hard palate may disappear spontaneously, 
durmg the progrehsire development in adoleyeence- And if the 
miiconB mi^mbrano should be slow in closing' over, this process may be 
expedited by occaaitmally applying a heated wire, or by raising and 
approsi mating the raw eilges. 

The Ai/fi pafate may bu fiaenred, alrme. Then, if the want of enb- 
Htance be not great, we have it in our power to attempt remedy by 
operation. Three circumstances, hcjwever, arc esseulial, as prelimi- 
naries to tbe attempt. There muHt be no great deficiency, otherwise 
traction in approximation wilt be considentble, and adbcBion will 
almost cerlaiiily fail. The putieut mu&t be of adult age, or nearly so ; 
great steadiness and eelf-cootrol being indispeHsahle on bin part^ both 
during the o[M?ration and aflerwards. The patient slionld also be of 
Bound Bysteui, and in gotid health ; bo as to afford every postiible 
facihly to the occurrence of adlicKJon in the wound. And unless a 
concurrence of these circumstances can be obtained, tbe pnidenl sur- 
geon will rcfniln from interference. 

The o|ieratio[i is termed Staphyloraph**^ or VelosffntheAts. It con- 
Bista of three distinct parts ; preparation of tbe velum, paring of the 
edges, and appro si [nation of the fit-aure by euturo, Tbe first part 
requires some considerable time for its completion. For weeks before 
the actual operation, the patient accustoms bim«lf to open his mouth 

* Nqvt JCn^Iond Qtmrtorly Juumal of Mcdirine und Sur^rv, April \MA. 





166 



BTAPfl^'LORAPHE, 



ot'a) 



vide, and to retain it flo, steadily and endtiringly — with di> effort at 
degluttliou of saliva : and he also ^eeks to reduce the imtaliilily of the 
pans, by frequently toyching them with his finger, or otherwise. The 
nalorc nf tlie operation is ftillj and candidly explained to tinij and his 
willing pcMiperatifm secured. Tlien he is seateJ before & good light, 
with the mouth widely opened, and the edges of the fissure are made 
raw, hy a narrow sharp-pointed hiBtoury, uaed as in harelip ; a vol^ella 
lieitig employed to seize the uvular estremity, and so to make the part 
tense during incision. This completes tiie secjod part of the operation, 
fiome time is now alloive^l to lEtervene, jn order that the ot^zing of 
blood may cease; and it is well to give some simple DoiLrishment — 
it being obvioufcly im]>ortant to avoid the eiTort and movement of 
deglutition for some time after approximation ha» been efiVcted. 

The tiiird part of the procedure consistfl in bringing the woirod 
inte accurate api)OB]iion at every point ; diminishing the strain on the 
autuies, hj lateral and jmrallel incision of the 
tDUcoufi memWane ; and keeping the pari in a 
state of as complete quietude as circumstances 
will |>osfiibly allow, Appmsimation is not made 
immediately hfler incision, as already slated ; it 
being obvionsly of importanee to avi>id the irn- 
lalion and iuvohintary aiovements of the palate, 
whit^h the trickling of hlwd would not fail to 
produce. But bleedinir having wholly ceased, 
there is no necessily for further delay. The 
necessary number of sutures are passed; and 
may be Mcnrod either by the ordinary knot, or 
by paflining the oral ends through a Hofl metallic 
bea<l, running this up to the line of w^ound, and 
clasping it on tlie threads ihero by means of 
firmly pointed forceps. Kot a few instnimeDtB 
have Uen contrived for facilitating the sewing department in this 
operation — undoubtedly one of great difficulty ; but it is probable that 
the curved needle in a fixed handle — as used for deligation of vascular 
tumours — will bo found quite suitable in experienced hands; or a 
Hhorl nee<lle, very much curved, may l>e conveniently enough paaied 
by means of a port^-arffriiUc. 

When appruximatiun has been completed, a longitudinal incision 
Ib made on either side of the palate, through the anterior muceus 
meuihrAuc ; so as, by ^^rmiUiug if\pan;{ion nt the cut ]>arl, to diminish 
tmction on the lino of imion. Ahacduto filarvation ib not dceirablo. 
But simple farinaceoufi fooil ia sparingly and <'areliilly admiuifitercd 
from lime to time; the patient being as |>assivo as i>ossible in the act 
of swallowing. And the ordJuaiy constitutional treatment, favourable 

Fl^. d2. Pljin iif 6iii^1i3'lutM]khp. TIip duuLib li^turo ia the act of b«iii|f ilmwn. 
Ttu' ilottnl lincTB mark tti? lilieradn^ iiit'i?ii<tiu of Lhp mut-oiu mvinbraiic. 




FiF-fla. 



BTAPHl'LOUAPHE, 167 

to the occurrence of adlieBion^ is of coiirse rigidly enfarced. Not a 
Uttle Belf-denifti ia neccsiiary, ou the part of the pfitient, to avoid tlie 
oEl-occiirriDg exciteTaeuts to coughing, banking, and Bwallovdng ; 
compliaijce with which would have a uianifetitl/ uDfavourable effect 
npon the wuund* 

Mr^ Ferguewn has fatroduccd a rery lugeDious modific&tioti of the 
ordinary operation; obtaining steadinesH and qdetude of the parts 
operated on, by means of myotomy. L-»i:iking on a split palate, from 
the mouth, the partH arc seea han<;ing ipiiet in the fauces, with a 
dUtiuet central gap In llie velum- If ihe flnpa be touched, tbey will 
be raised apward;^, by the actioi; of the levatorca jNxlcti mueclos. If a 
stronger stimulus he applied — as by the rude t^meh of a finger — "each 
flap \b forcibly drawn upwards and outwards, and can scarcely he 
distinguished from the rest of thu parUa forming the sides of the noBtrils 
and throat ; " and this is done by Ihu action of the palalo-pharyngei 
muHules, adiled lo tliHl of tbe levit^ires palali. On exciting the parts 
silunled morcj posteriorly, '* as in tho second act of deglutition, the 
raargina of thn fissure are forced together, by the action of the 
Biiperior coiatrictor muscle of the pharimx." The mniu opponents of 
approximation in staphyloraphe are thus shown to be the levatores 
palati and palalo-pbarvngei. And Mr. Fergiisson'a operation ia 
pliiuued so lib to divide; and temporarily jmralyze thchu uiiibclea. 
'* With u knife, whoHa ljla<lo is somewhat like tho |>oint of a lancet, 
the cutting edge being about a quarter of an inch in esteut^ and the 
flat surface being bent semieircul^y, an iuci^ion is made about hjilf 
an inch long, en each side of the posterior n^res, a little above and 
parallel with the palatine flapf, and across a line s1rai;;ht downwards 
from the lower opening uf the Eustachian tube. By ihis iticision — 
placoil about midway between ihe hard palate and the posterior 
margin of the soft fl up, just above the thickest, and most prominent 
part of the margin of the cleft — tbe levator palati muscle on each side 
is divided, juat abijve its attachment to the paliilen Neit, the edges of 
the fiseure are pared with a straight blunt-pointed bistoury, removing 
little mere than the mucous membrane. TLen^ with jl pair of loiig^ 
blunt- pointed curved Mieenre, the |>ostcri<jr pi I In r of the fauces ifl 
divided, inimediatf^ly l^ehind the tonsii ; and, if it i^eme necewj^ary^ the 
anterior pillar is cut across too; the wound in each part being about 
a quarter of en inch in extent. Lastly, tiie stitches ere introduced, 
, . , Or, it may be found more convenient to divide the palato- 
pharyng^us first, next the levator jialati, »ud tlietj to jiaru the edguu 
when the muscular action hao been taken off."* Wbcn the pared 
edgefi look thiu^ it may 1>e well to inci"eiii;e their breadth hy applying 
the curved knife so as to split the margins to a slight depth ; go 
rendering the occurrence of satisfactory union more probable. 

• Mffl, Cliir. TVsniuicl, voL ixvlii. {>. -i*}!. Alwi Fareuaftiiu'i PiUL-t- SafBwy, p. fiSl, 
FcfT DwIleiibach'A prooedure iu this aperati<)ii, we hia iiperatirc Chirurgie, 184^ p- 856. 




168 



DXCEH AND EXFOLIATION OF THE PALATK, 



By another mode the Bt^lit palate may bo made to cluBe- And 
to M, Cloquet we are indebted for tlie ekilful application here of the 
principle of contraction m the healing of hume, A cautery is applied 
to tho commiBsuro of Itic splits at suitable intervals, till^ after many 
liurns, tbe space is gradually ohliterated. Long time is necessarily 
occupied in the work ; but the means are neither pakiful nor hazard- 
oui;, iind the result though slow is eure.* 



Ulcer and Esfuliation of the Palate. 

The lining niemhraiie of both the hard and the soft palates is hable 
to ulcoratiou, from ordinary or Bpt'ctfic eauEca. The most intractable, 
and not least frequprit fisamples, are tliose whicb are connected with 
the mercnrio- syphilitic taioi of By^teni, In such, constitutional treat- 
ment is all im[>urtant ; the local applications varying, according to tho 
cbaracterB of the *ore. 

E:ifi"liation of the hard palate, not unfrequcntly complicated with 
cariesj aiid noccBsarily accompanied witb ulceration of tho correepond- 
ing raucous niembrane^ is soldom if ever found to occur except when 
mercury has been freely administered. Again, treatment is mainly 
conatitulionaL Locally^ separation in patiuutly awaited; and, when 
this has been completed, rt-moval of the sequestnun i^ dniy effected, if 
necessary. If the whole thickness of hoEie have perished, au aperture 
of catnniunication noccFsnrily reeultB between the uosal and buccal 
cavities. If tln'a be large, the deficieucy can be supplied only by a 
mechanical contrivance. If, however, it resemble a merely tifitulons 
opening, closure of the mucous membrane may be obtained by the 
occasional application of a heated wire. 



\ 



* Ifemrnre lur une melhwie d'apptii^ner la caul«H«liaa aux divisiopa anunualoi ilc 
c-ertjuufi orgiuefl, pt HpeciJilciiient dtuLlufl davinlu da palaii; pu U. Jules Goqupt. 



169 



CHAPTER XL 
AFFECTIONS OF THE TEETH. 

It is unncccBsary here lo enter fully on tljo viirimis and imiwrtant 
topics connected with the enbjectof thin cLaptcr. A few kadin^surgi- 
cal iJoinlH may be etatcd ; reference being made, on oiLer niatterSi to 
the varioua separate wurka which treat of Dt-utifitry in detail. 

Firet, it is well that tlie stiident remember bow affections of the 
teeth are not connected only with the convenience, comfort^ and g^>ocl 
lixiks cf a piLtienl — but with his beiilth imd very esiHten(;e, The 
cauEos- — sometimes reniotc, BometimcB tolerably direct — of mnny affec- 
tions implicating the general frame, as well as important p&rta of it, 
proceed entirely from the contents of the alveoli. Bad teeth *'are 
frequently the canse — and the sole cause — of violent and continued 
headach ; of glandular swcllingB in the neck, terminating in, or com.' 
bined with abhceas; of iudainmation and eiilar^^emenl of the tunails, 
oither chronic or acute ; of uleoralions of tho tong^uo or lips, oflcn as- 
Buming a mali^iint aclion from continued irritation ; of painfid feel- 
ings in the face^ tic doloureux, pains in the tongue, ja^s, &'c,;" of 
abscess and sinue of the cbeek ; of enlargement and change of struc- 
ture in the gum, which may lead to dnrgeroUB tumour of the bone ; 
" of diisordered slomLich, from aftVctioii of ihe nerves, or from imperfect 
mastication ; and of continued coimtitutional irritattou, whieh may give 
rise to serious constitutional diseiLse." 



k 



Crowded Teeth 

Are important in a snrgical point cf view. Behind, the irritation so 
caused may induce awclUng, vaflcularityT and ulceration of tho mucouB 
meTnbra,ne ; probably with rop^At^d attnoks of troublesome and even 
dangeroUB cynanche. In front, crowded incisors are very apt to cause 
abscess; not confiued to the soft parts, but itupUcating tbe bone also. 
The remedy is plain ; early to prevent mischief, by removal of one or 
more of the redimdanl organs; or, at a later ijeriod, to retrieve dis- 
aster by the Bame procedure— -removal of the cause. 

Caries of the Teeth 

Is the term employed to denote decay of tbe osseous matter ; which 
usually commpnces on Ihe surface, at one nr more jioinls, ajid proceeds 




170 



TOOTHAOH, 



inwardly until the pulp Is oxpoacd — the enamel also giving way at an 

early poriod. Wlieu the disease ia yet recent and linjilefl, its progress 

may be anealed ; by cleariog away llie disorn^anized siitstance, and 

*' Btoppfn^^' tiio cavity, dtbcr witli g^ld or with cement. 

Hnt a.fter tliG pulp han bomi fnirly exposefl^ and p&in 

cstablialied, Jt may be stut^ ah a general mle — not to 

be riwLly or often deviated from — that under Buch cir- 

eiimsUnces '* st^jpiiicg" is not advisable, and cstrac- 

linH of lUe offending part ia highly expedient. Long 

/y VIT tt) rciain a docayt'd t'loth, or jujrlion of a tiK>tb, h\ tbo 

^ ^ hojio of by varionw meana quelling the pain of tuothach, 

*^'^- and so avoiding tUe paiu of extraction, is to court the 

ncccsHion of some of tl^e more iuiporlant evil^ already ennmerated rb 

Hkely to sjiring liom such a soui-ce of irritodon. 




Totitftach, 

It ia important to remember, may proeeed from difT^reitt caTi^es ; and 
80 requires difU-rent Irfiilmcut in different eases. It may be an 
example of ncuralgiii, \^ill or ivithout any connexion with diseased 
leolli or gmus; requiring the ordiniiry an ti- neuralgic tieatuiunt, local 
and ^nei'iLl. It may h^ cjLiiHud by carii.-a uf tlie Looth, advanced io &s 
to expose tlie p'dp ; and then may be palliated by ancxlyneB ; t<?mpor- 
ftrily arrested, paiufnlly» by CBcharoticH; or eiiliridy queiiehed by es- 
tracllon of the tooth ; aud llie husl, as already slated, is in most cases 
tlio preferable proceeding. It may art^e from an inHammatory process 
in or anmud the tooth — in the interior of the tooth's cavity, or in the 
olvuulur investing pjirta— not necessarily cuiinetled with decay of the 
t«iorh at any pitrt ; and this form is plainly lo he aannogod by anti- 
pldogistit:^, local aud general : liK^ally, leeches and fomentation to the 
glim ; eonslilulionally, purgatives, antimony, and low diet ; the patieut 
at the name time affording as mucU rest as }>ossible to the affected part, 
eBpeciftlly avoiding all irritation of it by Itmgne, finger, or loothpick- 
Also, lieverp pain may It felt in the teeth, ap(Huendy sound, quite of 
A rheumatic oHgin and eharaeler; and ihifl te \o be got rid 
of by anti-rhenmntie reiaedie*:, mainly eonstitutioiLal in [heir 
Operation. Cbunge of structure in the fang cf the totith — 
it becoming coated by rough oBseotis ileposit — may induce 
intense ]>aia, though the organ be in other res[>ects sound; 
by Bucb hypertrophy, it is |irobable, the nerves are tucum- 
modcd and eonjprosscd ; and ihe only remedy is cstraction. 
And, lastly, the faog^ or fangs, of a lotjth mny beeome ue- ^' 
crowd, tUti crewn aud cervix remaiubg apparently sound ; chronic 

Fig- 6fl, Iltn>cl&s destmclnni *'f llie loipllu 
FV. fl*, I'arukilt o"*t «( Uxp fftHtf of a d«a>t4l lootli ; o(t*u ihc smiiU i>ri^ cf rauat 




EXTRACTION OF TEETH. 



171 



aWcss forms around the aflFtcled part, the matter aocumularing in n 
diafiQct meEnbranous pouch ; and much pain is likely to be thus occa- 
fiioned, until either the tooth \b extracted, orbecomea locBe and permits 
epoalaiieDiu evacuation and discharge. 



Extraction qf Tetith. 

Extraction of a toott is detuanded, not unfreqiiently, of the surg;eon ; 






rip u. 



HB-tt, 



as an operatioQ of itseU; or as a means towards th^ cnre of another, 
and perliap diitaat affection — such as neuralgia ; or aa part of a more 





h 



iis-ff- 



Ecrious opcTative ^rocedare — as in extirpation of a portion of the jaw. 
Forceps and the looth-key, are the inetnimenta ueually employed. The 
former, in general estimation, is by much the preferable ; equally certain 
to effe(;l the oUjecl in view; and ^Hjssessing lb© great reeommendation 
of exerting all tbo force on the doomed part, and leaving the aItooJub 

Fig. G5. Ditgram shewing thi^ application of die Knth-key, 
Ftg, eC- ForCTp* fiir lliK iijipcr jaw; iMiis;rucl&l so no tn o.!ji[jI tlieniKlvHi cloiely to 
Ltu> iottn tit ihf Euciitu III % Ihe tooih. sava iiLTUflK. ^Li^vm emtirni^ed. 

Pig. fj7. ForccpA for the lower jaw. In a, tho tooth cmbnccd 




HEMOHRHAGE AFTER EXTRACTION OF TEETtT. 

and gum compamtively, or absolutely, uninjured. Practice is, no douljt, 
essential to tlie skilful and efficient use of forceps; a^nd monj instni' 
menta are required in tte well-equipped annamentarium, adapted to tfc« 
ctinfi^i ration mid lodgment of the toolb to be removed. 

Stumps are removed either by means of sharp forceps, introduced 
beneath the gum ; or by a lever passed between the offending part and 
its alveolus, making use of a neighbouring sound tooth, if possible, as 
A fulcruni. 

SemotThage after Extraction. 

Troublesome bleeding may follow the ordinary extraction of a tooth, 
and may proceed from one of two causcsn An arterial branch, of some 
Bizo and activity, may Lave been imidicated in the injury inflicted on 
the alveohis. Or the patient may be one of those imfortiiimles afflicted 
with tho hemorrhagne diatbeais. The foTmer case is usually managi^able 
enough. The cavilv is sponged dry, and an eschamtic applied — 
nitrate of Filvcr, probably the preferable— so as temporarily to tirreat 
the flow, and afford a dry bed for the compress. Then, wilb all 
convenient Kpeed, slrips of lint, stee[;ed in a strong- tincture of matico, 
ate inaerteil firmly into the cavity, bj meaiiH of a slout probe ur 
director; and the ja^vs, having been brought together with a. com- 
press interposed at the injured part, are made to exert and maintain a 
sufficiency of pressure on tlie bleeding point. In the other case, the 
same local treatment le advisable, with the means rtuitable to the 
hemorrhagic diathesis. 

Tartar on the Teeth, 

Accumulation of salivary deposit is to be prevented, for obvious 
reasons i its presence bting prejiidielal to the teeth ibemselves, to the 
gums, to the mucous membrane of the check and lips, and to the tongue. 
The teeth are apt to loosen and decay, the gums to become congested, 
the rauuoiiii uiciiibrane to become llie seat of obstinate and paiiifitl 
ulceration- In effecting removal, care must be taken to leave the 
enamel unbjured. 

H«f«Pon of the Ovms. 

In advanced j-ears, and someiimes even in iniddle age, the gnms 
recede from the cervieefi tif the teeth, eepecially in front, es^jofiijig the 
fangB; occasioning looseness, pain, irritation, and final decadence — - 
though in other respecta the organs may be quite enliro. In the senile 
cases, but little c^m be done by remedial treatment; the occurrence is 
only a part of the general decay, and is in all respects to be regarded 
as such. A similar result may follow the accumulation of tartar ; it ia 
to be averted l>y removal oF the offending matter. Oougeilion of the 
gum£ may iuduoe itj and this catise is met by local abatraction of 




mJUBlEa OF THE TEETH- 



blood^by leeoliefi or scarification— and 1>y the subeeqitent use of 
Mtringent dentifrice^- At the Fame time it is very necessary to look 
to the stite of the pniUA! vm, and tu correct the irregularities which 
vill prolably be found there- 




Injuriea ofthn TcetL 

A tooth struck smartly may be deprived of a part nf its compftct 
structure, without any eerioufl injury to the integrity of the rest. If, 
however, it have beeu dJKplnced, and its vascular Cfinnection broken up, 
necrosis is the result. 8oinetimes simple dislocation occurs, without 
(ractnre. 

By replacing a die]ocati?ii tooth, an imperfect imion with iKo 
alveolus may take place; hut the tooth will eventually lose its colour, 
mud induce an unhealthy condition of the gitms< 



C. DeUbHJTH, TrniM* dr In SecomS^: D*nliiloii, PiirL's tSlO. F. Mnan-, TrfliLd Cnm- 
plctp 'le I^Artdu Demote, Pari*, IKty. Tlmma.^ \\f]], Anfll'rniy nnd PhyFtiobgy of Uie 
Twth, London, tR3^. Willkm RoberUon, Practical TrpatiBt? nii (he Hunum tv&h, 
LoDdon, lBi&. Cbitlj Clt-'ndon, On ExlrattiDii of the Teelh, London, IMJ- GoddarU 
uid ParkfT^ Anflloin^, Phyitiology, and Pitbolo^ of lluirian Tovthj I'hllulelplua, ]9i4- 
Jotin Tomes, 1j}<:ture? on Dcnlil PhyHiolof^y and Sur^try, LoDdfln, 1S43. Chui^in 
HvTia, M.D,, PriDciplen anil PracEif:^ of Dental Sur^'try^ PhiladdpLSa, 1S50. 



174 



CHAPTER XII. 



AFFECTIONS OF THE JAWS, 



Pandis. 



The tenn Panilis denotes the co mi it ion of Gumboil; iiiflaLnmation of 
ihe glim, iiHually cunitccted wiih a decayed luotli or portion of a tooth. 
The Bwdliug causeH much pain nud disoi>mfort, somellmes with smart 
const! nil ion hI disturbance. On Biippnration tAkiiig placOf relief is 

obtained \iy cvacuai'ntn of thi? matter ; but Rii long "is l^n" decayed tcxith 
rcTnnlns, n certain discbarp^G, ivitli swelling itnd pain^ contijiuea to prove 
the source of no slii^ht aniioyam'e, TreaLmi'nt varies according- lo tlie 
BtBg^ of advancement. At first, the affceiion jubl originating, tiie 
decayed tooth should h*: removed al once, and bleeding from tbe 
wound encouraged ; and afierwards, if need \n^y blood may be fnrther 
withdrawn l>y leecliing the afFeclcd part — the ajiimids bting moat 
coDvuniently flp[died ihroiij^h a glasB tube. When matter has fonoed, 
it should be early and fully eviicuated; and after the excitement 
following iutision Las abated, under ordinary aIlti]^lllogiJ>lie means, tbe 
offending tooth or stump should he gently exlr,u:ted. To perform 
extraction earlier, mii^ht be lo aggravate the inflammation nnneccs- 
sarily. 

When the m?tttor haM fi>nced and ht't'U ditcharji^'ed, estniclioo of 
the tooth Will ordiniirdy sufhce for eflWling: conlnirtion and closure of 
the discharging aperture, with subsidence of the s\sellin^ and paiii. K 
not, some of the muny suitable astringent solutionu may be applied to 
tbe part. 

Ejiufis. 

Epnlis denotes a solid tumour of the gum, of tion-inilammatory 
origin; but, like pamlis, often, if not usftally, connected with the 
presence of a decayed tooth, or portion of alveolus. It may he either 
simple or malignant, Tbe simple form is n Earcumalous groAvlb, at 
first eeoted in the soft parts of tbe giun, bnt tending soon to mvolve 
the ttiibjaeeTit bone ; in Nljort, tiie tumonr, at wlmt may bo termed its 
period of malnrily, may be truly considered an eKuniple of oateosar- 
coma, on a small scale. It spreads sloivly. Teeth loosen, and are 



TUMOURS OF THE LOWER JAW. 



17 



{!j 



aurroTiodccl by tlie flosliy growth ; Bud the body of the bono booomoa 
more am! more involved. 

la the earJy CDnclillon, it is Buffieient to remove the offending tooth, 
or piece of bone ; aad, witb a bistoury, to excise the altered portion of 
gum ; reprcRsing eulsequent tendency ti> growth, if need be, by the 
applicatiuEi uf an esuhanilic. WlK?n Llit bone baa bnuoim; Lnvolvtd, iL 
is Cflsential thitt the offected portion shall be laheu away — early, and 
freely — for obviana reasons ; and thia ia readily effected by knife, aaw, 
and cutting pliers. 

The malignant form is, fortunatelyj the more rare. Very early 
the hone b affected; and thu tumour is a true fijiccimen of osteo- 
cephfttoraa. Snon rhe surface ulcerates and fungaieh, with b]i>ody 
loathsome di^cbaj-gui and tLo dprn-Eul ia rapid in all directions. Ob- 
vionsly, the only reraedy is by ablation ; and that at a comparatively 
early period. 

Sometimes, malignant diaease commencjes in the upper jaw, not 
with the formation of tnmour, bnt at once by ulcffratiofr-r^>Bieocaiicer. 
The loss of subatanre speedily wastea the alveoli, and, opening into 
the antrum, disclos^K a foul and hideous sore — eouo beyond the reach 
of the most active surgery. 



[ 



Tumours of the Lower Javf. 

The lower ,iaw, like the upper, is liable to be the seat of a chronic 
colleclioD of fluid — here usually termed Spina ventoua — aa well u to 
be occupied by boih ytittoBarcoma and oeteocephaloma. 

Spina rentosa of tlie lowor jaw^ is, in trnth, an example of ojfco- 
et/stoma. The remedy ia bypunctur*^ aitd evacua- 
tion ; gradual contraction and consolidation of the 
cavity being sougtt for, by pressiu^ from without, 
and Ijy maintaining a tertain amount of inflam- 
matory process within— afi by a seton, or stimulant 
injectioD3. 

The solid tumours require the same treatment 
as in the upper jaw. But, with this differencef 
that, in consequence of the relative anatomy of 
tha piu'tft, camjilete ablation of an osteocepbalonia 
is witbiH our power at a much more advanced *' 

period^ than in the cobe of the supcnor maxilk; inaHmueh aa tbe 
whole diacjised strueture can be inciudi^d hi the incisions, and taken 
away- 

The simple Osteoma haa occurred in the lower jaw ; at first, to le 

Fir. SS- Cyst at Ihe root of n deoypd tooUi; lined by socreting ni*mbnino, and 
lilJcEi with puririinn liuid; cliTnnit'. Sappotwdto tv tbe origin, in many cues, of MteO' 





Pig, ee. 

failinff, ablation of ihe nffecled paJ-t is to Lt Lad recourse to, for even 
this simple rtnictiire has been known to degenerate. 

* 

Extirpation of the Lou^tr Jaw. 

Aniputfttion of the whole bone Lns been practified, on a«M>unt of 
Inmnnr ; but Avitli sjch a rcsnlt as scarcely to warrant repetition of 
the operation.* The dan^ra to life are msiny and almost insnperable. 

TJesiies tliose by loss of bleed, and 
constitiLlional shock, there is an im- 
mediate risk of BufTncaliun by tte 
UJicLintrolltd eom^itii^^n of the tongue 
and fauces. Inflammatory at'C4?fcHion, 
cansing rcdema, ie, at a more ad- 
vanced period, certain to cautic krj'n- 
geal obstruction^ threatening asphyxia. 
And, siipjKjaing these dangers pant, 
*^' '■' another remains, hj broneliinc or 

pneumonic seizure, cold air being at once and conslanUy ^^rlmitted ti» 

* Tbc bont. hureaver, liasbeon whiplly TpnioT«d, Uy plnralLt^' uf opfrnliEtiu, in {yinB«* 
quenw of rwurrencfl of tumonr — sncceaHfiilly.— LauMl, Ny. 1^57, p. 6. 

Fiif. CO- Oalpoanrcoma of Icwcrjaw. iTonl, smwlli, mm-ulctratin^. Slow in ^rmwlh. 

Fig. 70. OBteottplknlomui «frtrnRtr'l b-IUi tin? preceding. Sjfl, fun(f;oiiB» ulwmna, 
rapiiLly vnUir^R^t ami iuynlvUiy all Wxtiin-fl. 

Fi^. TL OAtcosarcomA of tin* ]Qver jiiw, Huperveniiiff uu oaiiA^itanu. — Ijatuv, 
Vide El'.tnentJ, p. 4m 





r 



ESTIfiPATlON OF THE LQWtlB JAW. 177 

the larynx ; wliereas, for a loDg time previoTiHly, atmospheric entrance 
had been by a must circuitous and gradual route, in conscfLUence of 
tho presence of tbe large obatructiug tumour. 

Partial removal of tho lower jaw is a very feafiiLle opera Lio u ; aud, 
as formerly etated, wben undertaken oo account of genuine osteoear' 
coma ifi seldom fi}llowed but by a fortunate isBue. 

Not unfref^iiently the jaw ig so occupied by tumour, as to render 
removal of ibo entire half necessary; by dJsarticularion, and division 
at or near Ibe symphysis, Aa incision is begun over tbe arUcu- 
Intion, luid couLiiiEK'd downwards uiid fi/rwardH, along tlje poiitcrior 
and inferior bordorfi of tbe bonc^ first on ita ramus and then on the 
Ifudv- Opp&^itfi to where it is intend^'d to saw the bone in front, tha 
forward course of tbe knife is arrested, and the instmrnent (h directed 
upwards to divide the lip— leaving, however, tJie ppolnbial [ortion 
entire. The flap, thus indicated, is dissected upwards; including all 
the soft [>art^ and fully exposing the tumour, Then tbe anterior 
[K>rtion of the bone, where eoction ia to be ran'vde — wide of tho tumour 
— is fully cleared of soft parts, on every aspect ; a tmith, if necessary, 
is extracted ; the external surface is notched by Eey's saw, and 
section is completed by stout cutting pliers. Now the internal 
attachments of the tumour and implicated twne are diviiied by the 
biattiury. And is llie artit^ulatiiju is approacbedT tlie iinterkr portion 
of tho bono is deprosaed by tbo operator's left band so as to faeilitito 
disarticulation; yet avoiding sucii an amount of presRiirQ as may 
occasion ftactiu-e of the altered structure. Depression boing- made 
by the surj^eon, and an assistant now compressing the common carotid, 
the muRcular altaciiments to the coronoid process are cut across, and 
afterwards disar lien 1 alio n is effected; ihiH part uf the operation being 
oompleled as rapidly as puasible, from before bnckwar^la, opening tho 
joint in front, and with the knife's point moving closely to tbe bone, 
so ati to avoid an unnecessary loss of blood, Tbe bleeding vessels are 
then tied at the u]iper angle of the wound, either singly, or by deli' 
gation of the common tnmk of the temporal and internal majilkry 
arteries — which may happen lo be eJiposed — by means of an aneurism 
needlOi The facia], temporarily commanded by tbe fingcra of an 
a^ifltant^ ia last secured. And then the flap is replaced, and relainod 
by suture ; the entireness of the prolabium in front obviously contri- 
buting mncii to the facility of accurate adjustment. The wound, in 
its major part, is likely to heal by adhesion ; a portion suppurates and 
gapes, not inopportunely, to permit suitable discharge of llie purulent 
secretion from wiLhia. Dressing of the interior is conducted aa in the 
case of the upper jaw; and consfilidation, with reparation, in like 
manii<?r results. During tbe process of cure, material benefit will 
sometimes accrue from tb^ use of a mechanical contrivance, adapted 
lo the teeth, whereby overlappiiig and displacement of the mutilated 
pan is prevented. " Metallic capa are fitted to the teeth of the upper 

N 



ifS ESTiKPATiON" OF THK LOWER JAW- 

and tow^f jawB of ifie sonnd side, and are rivfft^tl anil soldered together 
%i their baeeB, so that, when applied, they Bhall bave Ibe effect of 
preventing the dra^ng of tbe remaining portion of the bone aod 
chin tu the opposita aide by the external pterygoid, mylohyoid, and 
digastric muscles, and by Ibc elasticity of ibe Bofl parta. Tbis appa- 
patuB should be woni tor many weoka flfter the oporulioo/'* Contri- 
vanoefi m.iy also be t^rmporarily worn, on the injured Bide, to prevent 
undue sbrinl^inp of the cheek, during emulation. 

A tumour impbcaling tbe biKly of tbe bene only, on one dde, may 
be removed by a similar but lees extensive incision; section of the 
bone being made at (he angle and eymphjaia- Bui tha propriety of 
Buch a procfcdiug ia very <iueHt ion able. Experience hua shewn that, 
in finch cases, relnrn of the disease is very apt to takp place in tbe 
tniiicated ramus; and when tbiB happens, Jifljcnlty of disarticulation 
ia found to l»e greal, from want of power in depresBiog the c,oronoid 
procesa, and conBcquenlly in dividing the in&ertion of llie tempond ^^ 
muscle* It ia expeiUent, tlien.-fore, in all such casea^ to anLicipftta ^^M 
return of the tumour, end the difficnltiea of a second operation, by at ^^% 
once performing disarticnlation. Be^idf^, this is a principle of ope- 
ration quite auiilo^uH to vrha!; delemiines excision of a lon^- bone, 
affected hy tumour, rather than ilB partial removal; preferring, for 
example, amputation at the ahoulder joint to an ot^ration with Bection 
of the booe^ ou actouut uf tumour of Ihu buiiioruB. 

SomclSmea, though rarely, osteosarcoma originates in Ihc ramiu. 
Then it ie necpRSFiry tn effect disarticulation, after performing Faction 
at or near ibe angle of the hone. In such a case, it is expedient to 
grafip the ramus, lifter section, by means of firm and sharp -jjointed 
forceps, 50 that the reipiisite lever-]X)wer may be obtained for depression. 
Also^ it may be possible to effect thia operation, without openliig the 
cavity of the moutU.-j- 

The symphysis may be removed on account of tumour; a hori- 
zontal wouml being made along; the lower border of tbe bone, with a 
peT|>endi<:ub(r incif^ion at each exlremily, leaving the pnilabial surface 
entire. Section of the bone is made partly by tbe saw, partly by 
cutting pliera ; ihe requisite teeth having l»eeu previously estratled. 
After esdHion has Ijccn effected, aotue care of the ion;ipie is ntccsoary ; 
lest nfler division of its autf^rior attaehmentg it should he unduly 
retracted, and threaten asphyxia. To obviate this, the organ may be 
temporarily restrained either by ligature, or by forcejis. 

Sometimes it is necessary to remove llie symphysia along with one 
half of the jaw; the tumour being so cstenaive, Thie is effected by 
Biuh a form of incitnou as recommended for dir^arliculution with section 
a1 the RyiiphyRis- 

Sometimes it is expedient to i^movc a portion of the jaw, on 

■ Ijhti^mV Vrfctiful Siirfl^ry, i-. 3t8, 
t Svur, Ijmitiin H&d EdioUurgli KTe<1kal Jmimul, 1M3, p. (Mt4, 



1 



Fa.\CTCRE OF THE LOWER JAW, 



179 



ftceonnt a( nicer or tumour of the ?oft pnrtB wLipli htm implicated the 
oaeeouB tissue secondftrily, Oae paramount indication must in all 
caaes be fulfilled : to remove the whole of the morbid atructnre, and 
to cut wide of the diBcaee. 

During these operations on the mouth, it is plains for reasons formerly 
flflflignod, that chloroform, if emploj-ed at all^ must be oeed warily. 




When either of those affecliona 



C<irifs and Necrosis of the Lower Jaw. 

The lower jaw is liable, like other bones, to these common affec- 
tions. But, in the prcBent day, it sufferB much iesa frequently and 
CTtteneivcly in thia way, thnn it did 
when mpreimnhziLtioTi was more id 
vogue for venereal affections — real 
and suspected. Many teeth, large 
portion« of tiie jnw, and even the 
greater part of the entire bone, not 
nnfrequcotly were tediously and 
pftinfnlly diechnrgdd, as worm-enten 
BeqneBtra ; causing much disturb- 
ance, both local and genera], at the 
time, and ^eaf subsequent deformity- 
do occur, the general principles of surgery are brought to hear on 
them; by treatnient partly lixial, partly directed to the ayBlem, 

Necrosis of (he jnwp, from the Qgency of phosphorous acid, generated 
in the manufacture of lucifor matches, has been already alluded to 
(Principles, p» 415)/ 

Fracture n/ ike Lower Jaw, 

The lower jaw may be broken by vioknco applied either directly 
or indirectly. Frartore nenr the middle of the body of the bone may 
be the result either of a blow delivered on tJie Hymphysis, or of irjury 
directly sustained by the part frjictnrL-d, The body of the bono is 
most frequently injured, but all parts are liable. The ramna has been 
Assured, the condyle haft been broken off, the coronoid process baa 
bepo puapt through, and the Bymphyeis itself has given way. The 
fracture may be either simple or of>mpoimd. Aloioat nlwayw, there iR 
laceration of the mucous membrane, with consetiuent bemorrhajje into 
the month, and exposure of the fractured ends in that direction* The 
signs of the occurrence are sufficienliy plain ; by deformity, crepitUB, 
loss of power, and evident displacement. The menttil portion isusnally 
displaced downwards, by mnocuW action, 

" Vide also Iavcet, No. 134;7, p. 4DB. 

Fig. 72. Ulcerative dflatmctlflii of the coraiioid proceM of the hiwer jaw, ciiiued by 
'■the Bkkward pusLtion of (he irisdum Ux<tb." The patient *' petialiod in »imquenpe i>f 

Ih4f eileDsiro ab*ces»a of thi> naciutb and ceck'^LiBTON. 



ISO 



DISLOCATION OF THK LOWBR JAW. 



Heduction ia easily effecfed j and, uauaUy, retention is not diffioolt. 
9upi>osiiig tbo fracture to he ftt JtH ordinarj jsife, Tiear tlie mii^dle of 
the boily of tlie bone, the fragtEieots are carefully juljiisted, with the 
lecth iiJ a line ; wid two wedges of cork, alojjing gently bickwardB, 
with tteit upper and nnder siirlaccs grooved for the reception of the 
upper and lower teeth, are inserted on each aide of the mouth; the 
jawh having been firmly closed on thorn, a pasteboard splint is adapted 
lo tho exterior wiirface ; ftiid the win>le iH reUined hy pnitJible bandag- 
ing, The object of the wedges ia twofold, anil obvifusly beneficial ; 
namely, to secure accurate apposition of the fragments, and to kave a 

vacfljit space in front Buituble for iha i>as- 
Ragt uf fluid uourishnient without move- 
ment of the iMLrt*. Tho objection to their 
tifle is, thai, ilr foreigti bodies, ihey may 
cause saliuition or other iacQaveaience ; if 
thin should hapjHiu, they can readily be 
removed ; and meanwhile by their tempo- 
rary jireHt'Uce, considerable benefit may 
Lava bocu obtained. Sometimes, if firm 
teeth oi^eiipy the verge of each fractured 
portion, it miiy be well to Becure these in 
appof»ition by silk ligature. Teeth qiute 
detached should he removed at once ; 
^t'J^ y.ud so ought frHguieul8 of hone siiaiUrly 

clreuiuBtanecil — in caacs of coniiDinationt For eomo time the patient 
rouat l>e content with aneh arlieles uF Food n^ require no maatication j 
and all movement of the frattvired part must be avoided. 




Dislocation of the Lower Jaw. 

Dittlocaiiun iif the jaw is fjmardB ; the cnndyiea in front of tho 
baee of tlis zygomatic prooeRH, and the eorimuid pruCL'sses reefing on the 
ed^e of the malar bone,* The accident may he complete or partial ; 
according ft8 ono or both condyles are difejdaced. And it may be the 
result of tnere muscular action, aa in yawning ■ or of force applied to 
the symphyKis, with tlie mouth [uore or less o|)en. Tho month gapes, 
jtnd c«nurtt he shut ; the chin is dcpresseii, und saliva trickles over it j 
the cimdyloiil Kpace is vacant, and prominence is felt beneath the zygo- 
matic proc^^Es ; considerable pam is ex^iericncedi and articulation is 
very indistinct — perhaps altogether ohstrncted. 

Kednction is cfl'ccled by a comhined movement; depression of the 
angle, elevation of the symphjuip, backward prcBSure on the coronoid 
prooofieee, and traclion forwards i>f the wbok- bono. Thus (he bono id 

* KeUldn, McmoLfrj dc la Sadet^ dc Cbirorgie de Puis, 1B49. 



ANCHTLOSIS OK THJC JAW. 



131 



extricated irom its ent*inglement ; and brought within the ancontrolled 
play of the niiiHcleB, is by them pulled back mto its normal position. 
The tbumbST placed over the last grinders, within the moutli, effect 
the Rrst moveaient; the rest of the bind makes the estertKiOTif with 
elevation of the symptysis i and an ttasistant pre«teH back the ci>ro- 
noid processes from their rest on the obeeli bone. It \b not necessary 
to protect the tbumljs, by a towel or olherwiEe. Ah the jaw ia felt to 
yield, they are made to slide on to the alveoli on the outer side ; and 
the snap, irbich jLccompanies and denotes replacement, finds ncjthing 
interposed between tlie teeth- Foraome days flfter\viirdflT the motions 
of the jaw eboidd be very Ibiiittiil ] and in most v-^ases it is well to 
restrain them by a bandnge. 

Artchiflosis of £hf. Jaw. 

This may be spnriouB or real ; the result of change in the suft 
partfi or in the hard. MB^ticatiun, degluiitiun, and speech, am sen- 
oufily interfered with ; and the patient anxiously eeeks relief. This 
maybe itffnrded by the knife alone^ i^'hen cicatrices are in fanlt ; divid* 
ing adhesions, and preventirio; reunion by carefid dressing snbst'quently. 
Sometimes, in addition, Bubculaneoug section r>f the masKCtcr is advis- 
able-* When rigidity is txlremSj and depends on true anchylosis, it 
may be necet^H.rv to oiierult on the Jaw ilaelf, in order to prevent 
death from iaonition; Bawing the bono throng'h, so a& to make a false 
joint; or removing a central portion entirelv, for the admission of 
food. 



On romovftl of the jaw, i« Kowker on Dimhah of the Jaws, Stc, Jjindon, 19?S. 
fiovtir, MurinJrc nar t'A.]iiputatmn dc Van maxilliirv EiifirrLcuri In Jr>iu~iu] Comptcm, du 
DicL de4 Soitnceft Mcdicalce, Dupuytreu* Le<;oua Orated, MuLt, AmerJcaa M«diul 
Recorder, toL L Cuaack, Dublin Htupiul ReportA, vdL iv- 



FHBOiir«^'N, Pructiail Surgnrj' jp- SiJ*. 



Ml 



CHAPTER Xlll, 



AFFECnoyS OF THE TOXGUE. 



Gkmita. 



Tbi inltfiBaMT jnam b Aft fcj i ftM haj 1w v»doiis]y LDJuced ; 
■ umA, tfi^h «v ether ■^■iiM , hy ptjiKnck; bj &cnd ftpplicBliond, 
Or it ttftj oc0«r ^•Mt>BMVB|7- IW gy p t uift are— pain, saelltfi^, 
vKtUm, iM^ttflB duittt aifuivaBt cf ike oi^narr funciicns of the 
orgiik. Id «xu«m« cum, ike svellm; ouir occlude the fauces, and 

The trejuiueDi is hx theowmum or connteracticiQ of tbe cause ; 

leedbet to the pan, or iK« openii^ of a rmaioe vein ; aini t]i« ordiaory 
uitipUogudfs int^mallj. Tn casei of iir- 
ITPiiCT, *^ need iwi hmuie lo make loiigi- 
ludinal incisioas> freelv, as tf for ph1egmoD4>ua 
eTTsipc1«5 ; the escape iif blood h copious, the 
f'Xtii.W fluids also find a ready exi^ usualJy 
ihe swcUuig rapidly abalef, and the woiindB, 
whiob at flrst wera gaping and deep, dtritidif- 
down to mew scariQcations. Tbe aottphlo- 
gisiic Tcsuh is sadsfactoTT, and do important 
ksioQ cf structure is inflicted od tbe part. 
' Should a case present itself too advanced to 

adtnit of waiting fnr the effects of inciaion, life must be saved at all 

hazards— by broochotomy. 




Wounds of Ihc Tnnjttc. 

Wounda of the tongue bleed copiouEly. Hemorrbage is to be 
^ommandcil by ligatnrp and styptics ; if nettl be, ihe caulety may be 
■pplicd. In iiniling tbe woiinil, nft^r bleeding bas ceasoJ, it b pljjiii 
ibat WD can avail ourselves only of the comnion inten-upted sntnr« — 
othor releulive means being inappliL-able lo ibe part. In the slighter 
cases the ime ol" nutures may effect not only approximation but also a 
hcmoBlftiic resull. 

Fig. 74. Tongue swtttn, Lv glw«it«. 




nVPERTROPJlY OF THE TONGTJf;. 



133 



Ulcere of tbe tongue, like those of the iips, may be eittier aimple 
or trtulignnnt. The Ibnner may depend on IocelI irriiatJan, us from 
tartnr cr deuayod teeth ; or on gnatrio LrHtat]t>Q ; or od a gctieral 
febrile condition; or on a nn?rcnrio-Byjihi- 
litic slate of system- And the trcat- 
iDcnt, it is obvious, will vjiry accordingly. 
The preferable local applications arc — 
uttratu uf Hilvur, either in suhsLunce vr iu 
Holutjun i FLudi in obetiDate cadca, the fluid 
pemitrate of mercniy ; tlie former applied 
frequently, the latter at long intervaln. 

The malignant ulctrs are to be got rid 
of by knife, ligature, or cautery. The two 
finit methods arc UKiially tu he preferred ; 
and due care must ever be taken, tliat the 
whole of the apparenily diseaeed partr with 
a border of ap[iarent]y sound teitaro, is 
removed. 

Persons of advauced years ehould be 
very ;:areful to avoid all cinlinuud Lrrita- 
fjon of tho ton^o, oa by tartar, false 
t«eth, S:c.j lent (roiibleRome and nltimately mn]ignan1 nVpration bp 
induced. 




Fif,Tfi. 



Hypotrophy of the Tongiit. 

The tongue ib occasionally the aeat of Bimple enlargemeat — con- 
genital, or ocqnired- The normal texture is grn/hially exjianded; and 
the papillte become greatly enJarged. Much inconvenience necessarily 
remiitaj even ihougfc, aa usually happens, the jaw in some proportion 
accommodates itself to the altered interior. Ultimately th« ton^e 
protrudes; and a wasting di.schar^^e of saliva necessarily resulwi. 
Deglulidon, articTiladon, and oven hrcathing-j are more or less inler^ 
fered with. 

The treatment is by rectification of the primce vife — nsually very 
prominently disordered \ by re^jeated leeching of the purl ; and by 
internal a<l ministration of the iodide of potassium. Bandaging, too, 
may be applied £0 the protruded part. And such means, patiently 
employed, have obtained a care. But should they f4ul, it may be 
eipeJient to remove a portion at the apex, of a wedge shftpe, and of 
such a size as to restore the orn:aQ to somethiu^ like its normal bulk, 
on approximation of tlie wound's edges; at lewsl rendering the organ 

T\g. 75- Excnvatfd moli^nnr ulcer nf ih« root of the tongiLe^ (Eclemt jfl^Eidia 



F 



IM 



mmcBsor ths Toam& 



of raadence within ik« iBMaJk^ io iiiiiaipln|^ th* pciiicipsl 
AJmitMikf flttil Kiu:uaTeiiieoc« — protnuon — tod redncing tlie rif^ of 



in^hr^tum^^^ Ti 




iBMead of ^i^BTgoB^ a genoml li jpcjtroplir, tnaj be 
hf partid fnlngiBnt ; certain ponkwfl bneaauii^ ^lerabed, 
\ar^ 9mJL pucful — beia^ tfe Kst of a chronic IndAJsnutorT ptoc w of 
Iw gn^ T^ sw«f^n^ WAj rottUB of an inJoJeat aAlnre^ bSowIj 
c Atugtika' iBliiBUT. Or tb«j maj ^lovly eappimte; 

I ap ert m g ; th« ^nenl ip^wvmtce of the port cUweh '^'n^lnfmg 

Tbfr TTmiwnf ii ■• far hyp ar t ro pfcT, bf leedaig, altentiTes* uvi 
***T''i*tr^ t» th» pdma nn. In maaj caass, the mternal use of usenic 
hM be^ iwad of ffgntl btaefit. And, vh^^a sai^pahUa, iodide <^ 
potMnM, w ea k^ lul^ a ewtioB aMoae t>f m^rcunr mar be adni* 
HMtjr< if TIm oi^bMBtiaa n DaBowan'a Eqtaor o^ec prriTfs oaduL 
TW ■■btfalthT cftTttMS made bj inr|ntnrtmi are to be exposed by 
potoi^ fn^aniind; aadthcB MBddDttnBtkiB nuybe expected. 

Tb« «f«ctile tsBovr nar far* in tb» «rgab. A Uw ^xampln are 
od nmtd- If ibe djgawd tfnwtBn b« fiuted and acc^^ibk, it is to 

be i«flK>Ted by ioclnsioD in liga- 
tir& If ittDTDlTe tbevhole organ, 
«r be otberwi^ not am^Qible to 
deli^tioa, attempt nuy b« made 
li> iodoci; a remcdiAl change of 
CTni^lnPe, ertber bv Titration or 

by pljksdc cxndadiin. Foiling this« 
the disnsf must be reganled as 
__ beTTOd the reach of our art. De- 

** ^ ligaixw of Knb Hngnal arteries has 

been prA«d9<d ; bat idth a rv^t «tucb ^<ie5 not iDTite repetition ; fatal 
akrnghtDg of tbe <vrgan ensnod.* 



1 




On account of maligTiant dt$e«£e, ooctilt or open, as well as on 






1 



UlVieiON OF TnE FR^NUW. 185 

ftw^ant of erectile tumour, it may he necpseary tn remove a part, of the 
toD^o- Malignant disease involving tLe whole organ maybe regarded 
as irremediable. 

Carcinoma and Cancer ahew their ordinary characteristics here, 
and fullow tbeir usual conree. A detailed staiement of the symptoms 
and progress of encb ftffceiionB is ttiercfore iinneccpsftry. 

Removal may Lg effected either hy kmfe or by ligature. The 
former is employed when the doomed part is situate anteriorly, and 
not extensive; hemorrhage, under such circumstances, being readily 
Ubd«r controL By a volsella the part is Bei;ced, stretched, and made 
to project outwardly ; and by a bistoury Balisfaciory ablation is leisurely 
and careftilly effected. Hemorrhage bavins; bcun arrcEtcd, llio wound 
in approTimated by siitiirp, if its flize atirl fi>rin jn^rtnit. 

In other eases, the ligature is preferred. A fttoul cord is iiassed 
on the proxinuil as|>ect of the diseased part, in sound textnre, by 
moans of a large needle in a fixed hutidle, as recommended for erectile 
tumours ; tbe Doose of the ligature tiaving been diTidcd, each half is 
drawn tight fleparatfly, so as completely to ianlaio and strangulate tbo 
dUejised portion ; and it is well to notch with a knife the line of 
constriction, previously, &o that strangulation may be at once complete. 
By whatever mode removal is effected^ the prognosis mnst be but 
gloomy; for it can be rea*lilj understood, that return of malignant 
disease is but too probable, in an organ whii^h has been only in part 
taken away, 

Somelimes it may be warrantable, even in avowedly hopelosH tir- 
cnmslanceflj to remove a malignant ulcer of tbe tongiie hy operation, 
solely with the view of palliation.* 

Divmon of the Franvm. 

In tbe child^ the frfennm lingiiro may be so short aa greatly t<i 
incommode the organ ; at first impeding suction, afterwards embar- 
rassing arlicuiatiijn. Or the defect may be more accurately expressed, 
perhapj*, as an Jibriormal prolongation forwards of the fra?nnm, tying 
down the apex of the tongue, The faulty textnre is readily divided, 
by meiina of probe- pointed sciaeors — the point of the tongue being 
elevated, eo na lo stretch the part, hy the finger, r»r by moans of a split 
cflrd; and, cutlinjif rather on tbe jaw than on the tongue, trirtibleaome 
bleeding by wound of the ranine vessels is avoided. During healing 
the part should he manipulated bo as to prcvi^nt recontraclion. 

In the adult, a somewhat similar condition may siii>ervene, in 
conaequcncc of Iroubleeome Euppuration beneath tbe luugoe, During 
cicatriiyition, the aptx of the organ is drawn down, and hocomes con- 
fined by a densy band of advenlitions formation- This npurioiiB frienom 

■ See BiuiKeTT on Canccraua and Cftacrgid Growth* p^ 1^. 




ISG ItANULA, 

raaybe dissected lhroii!j;h; and, by dint of careful dresdng* a more 
favourable cicatrix laay be obtained. 

Rantila. 

Ranulft dei^Qles a tumour^ forQi^^d beoeath Ibe tuDgiie, in coDse- 
qiience (if obHtructioo in one or Lolii uf the Kalivary ducts. It conBifltH 
of a oy^t, [irodiiccd by cxp-iiiHion of tbe duct, and 04>ndi;i]SFLtiun of tlie 
BUrraumling parts; containing iierverteJ secretion of tbe cystj and of 
the correaponding; salivary j^laud. Nut unfi^quently, there ia good 
reiutou to bt^Ucvo that tbe i:-ysi lo nut a dilatadiin uf nuruiid etnictun^ 
but A now formsLtioii altogether — -like cystic spellings elsewhere- In- 
conveniencp is felt in mastiL^ation, dej^lniition, and arlicidation ; indeed, 
the term Rannla has heen appliel on account of ttic croaking ehange 
of voice. The tumour id dislinclly seen on elevating the apex of tbe 
tong;ue ; and but alight manipulation ia nec(^s5ary to aBccrtain ila cyRtJo 
Aad bB.\iVH.Tv Jiatnre. 

Two modes of treatment are applienble ; rcptun^tion of the normal 
opening, or the making of aii urti^clal Eubstitute. In recent caaea, 
the furmer niL'thod may eiiccecd. The o<:cluded original orifice is 
diluted, by prubea of suitable dina<?n3ionE ; and tho due degree of 
patency and calibre is subsequently maiiituiued, by the occasional 
paeeage of a buugie or probe fur some lijne ufter^vaida. In luoHt 
caHcs, howeverj an in the Eomewiiat analoj^ous tirfiimtiUineea of Hub- 
cntaneous encjeteiJ tumour — the m^mial oriiicie cannot be detected and 
I'efitored, An artificial openings is made, ai an anteiinr and dependent 
part. The contents rea<lily escape; but they soon re- accumulate ; 
and the difficulty In ihe case consists in keeping this artificial opening 
90 patent as in allow of t^uubtant diHchargc, »nd ci-insi^ipifut coutractioji 
of tho eecieting aynt lo the eopaciiy imd character of the original duct. 
To effect our object, it Ls well to touch the aperture occasionally with 
the potassa fusji, aa if lo compel citatnzalion of the margins without 
closure. And this object may be fnrtlier fadlitatcd^ by the occafiional 
use of a large probe or Ijougie, afler tltc caustic has been ^lisusei. 
Failing in our nLlempta Ihu^, ik &;Iod lis pus&vd through the ^ysi, and 
rctuincd until the rcjqirieito c^onlriLClion ia obtained- A piece of bilver 
wire — retained by twisting the end^ — may Foinotimcs he found more 
suitable than the caoutchouc tape, or skein of silk or cotton. 

Tvinours beneath the Tofigttc^ 

Enc^^Ud ttiT7\oitrs are not unfrcqucnlly found in this situation; 
aimnlaling the condition of ranula very dosely. The cyst is thin; 
the contents are clear and glairy ; the size may be considerable. The 
remedy is by incision and cauterization. The cyst is opened anteriorly 
by a fj-ee pimcture ; the contents are allowed wholly Jo escape ; and 



SALIVARY CONCRETIONS, 



187 



then to the lining membrane is applied either Uie niLrale of Bilver 
finnlj, or the potaesa fusa lightly ; care being taken to confine escha- 
rolic action to the part intenJcd, After the ns© of potass, rinsiiiff 
of the mouth repeatedly with vinegar and water is n ealu aitd prudent 
precAatioii. 

Faity tumours licncath tlia ton^o huvo aIbo simulated raaiila. 
The attachmcntfl are delicate and kkoee ; aniL, for exlirpatinn, littlo 
more thaa mere iiLciaioQ of the investing membrane \& sufBrient. Fur 
obviooa reasons, removal by the koife cannot be priictised too early. 

la the afler treatment of suppurating wonnds in tbiA locality, it has 
already been stated that care must ho tnkeu lest, by cicain^ailoD, the 
condition of tongue-tiQ bocomo (ifitahllEhod. 

Sctlivarif Cancretionji. 

Concretions form in the extremities of the Whartonian ducte, more 
^queuLly thait in contiexifjn wi[h the jiarutid gland; with or wiiboui 
obetrnctiori of the ealivft's coiirsc. InconvcnJenco is cont^iderahlcT hy 
the bulk and irritatiim of tho forei^ snli^tanco. By manipulniion and 
use of the probe, the presence of the coticretionB can, in most cuaes, be 
very readily detected. When of large aize, 
they become fully exposed in the progress of 
working tbcir own way out by idceration, after 
the manner of a Bequcstrum, or any i>ther 
foreign substance. The operation for removal Ki^ 77. 

la then simple; after Buitabk inciHion, the calcnliis is kid Ijold of by 
forceps and extracted. But ivhen the foreign body is small in a large 
containing cavity, it may retreatj aiwl elude the attempts at seizure, 
In such a case, let the patient masticate any agreeable article of food ; 
and by the outward cnrrtnt of saliva tht concretion will be either 
washed awny, or at least made prominent and auperfietal. 

On cnlirgeme^it of tbe ton^e^ »ee Parcy, julicle Lang^te in Dli^L ilea ScicncpB Uedj- 

Edin. Med. flnd Surji- JtiunL rot. L p, al7- On nlTtctions of the longuo in general, aw 
Brodir^ Lancet, Ni>. 1050, p. r'U6. 




fig' 77, SaiiTvy caiculoi, of comidenblc Hize remorvd by opentiou. 



188 



CHAPTER XIV, 

AFFECTIONS OF THE UVULA AND TONSILS. 

(Edema of the Uvula. 

(Edeiaa of the iiTiilii, with a relaxed state of the neighbuuring Hoft 
palate, may occur singly; but more frequently it is the result of 
An iraperft^ctly resolved iuflainmntory afFectiuu of the whole fauces. 
There le a feeling' of very ctingidemUe discomfart iu the part; the 
qonlity of the voice is altered^ fliliciilalinn ;a impeded; and not nu- 
frwjuflntly e. tickling and atiiioyiiig cough txislB. TLe vanous astrin- 
gent garglea are of service; witli attention to the general pystem* 
Failing these^ Htiinulanls and astriagents may he applied directly to 
the part^ in solution or in po\s-der ; as alum, capsicum, tannin, &c- 
Or the pan may be touched occosiun ally wiib Iho nitrale of silver, or 
pulphato of copper, in stihaUuce or ablution. In ohstiriftte caaeSi it Lb 
well ihftt scarifieiition precede the last-named remedies. 

Elongation of the Vvula^ 

Relasatiuu of the uvula, viith elongation, is of no imfrequeot 
occurrence; thu estreinily of Ibe orgau jhaeain^ dovrnwurJs, and hy 
titillatton of the glottis causing a very unpleasant and sometime* 
distressing cough. Sometimee the extremity is fcderaatous and bul- 
bous ; HomelimcH it is ibin and fimbriated. In the slighter cases, 
ordinary astringcDls and stimulants racy he tried. Bat when elon- 
gation ifl considerable, es regards both extent and duratiiJUj there is 
no Buitahle remedy hut hy catling (.jff tho redundant part ; an operation 
which has never yel been followed hy any untoward consequences. 
The patient* sealed before a gtiod light, is directed lo cough, bo as to 
bring the pendulona uvula oa the dorsum of die tongue. Then a 
suitable portioa may be at once cut off by the stroke of sharp cutting 
scissors — probe 'poinled, lest the [>atient should prove unsteady. Or 
— better — hy a vulsella the apes ie laid hold of; and then, by sLietchiiig 
the part, section will be fiicililjUi^d at well as roiidert'd more nccnrate ; 
care being takpn n< ft to stretch until at the instant of cutting^ otherwise 
troublesome retching is apt to ensue* Complete extirpation of the uvula 
has been recoromended in such eases, on the plea that re]a|iBe is other- 



r 



AB8CE88 OF THE TONSIL. 189 

wise probable. But, even supposing the fear lo be justly founded, 
siich a riitblesB proceeding ia scarcely warrauUible ; iLc organ being 
donblleE^ endowed with some useful fuoction i& tbo general economy. 

TunsiltilU or C^/ianchc Tonsillaris. 

This term denotes an inflammatory affection of the fancefl, chiefly 
resident in and around the tonsils ; ordinarily the result of atmospheric 
ca^podnrc ; and cLaractcrised by HWtlliiig, redneas, heat, and P'^'* ^^ 
the paHi impeded and pHinful deglutition, inn-bility to separate tht^ 
jaws. dlfGciilt articuIat]o[]T marked ulteraliou of the voice, and the 
ordinary constitutional acconipanimentB acL'ording to the inteit^ity and 
advanceraeat oF the process. Treatment \s by ordinsry antijihloji^iHticB, 
local and general. Scarification of the part is aometimefi advisable, 
with the view of abfitrading blood, controlling swelling, and rendering 
si]p[mratiorL lesa likely io euperveue. Sometimes largt^ doses of guaiac 
— half a drachm of the i>owder, thrice daily — have a resolutory aod 
almost specific influence ^ Dover's povider, loo, is often useful in a 
dmilar way. The affection may prove formidable by assuming the 
erysipelatous type, and spreading do\i'Dwards intti the air passageB, 

Abscess of the Tonsil. 

An acute absceets of Eome size, in the tonsil, requires active sm-gica] 
interference. If all^twed lo follow its own c;om■^ie^ much distreBs is 
likely to be occasioned by |>ain and MvelUng, cic cvacualion and 
anbsidence take pla<;e ; indtcd, Lht? swelling may bo sueh aa not only 
lo prevent deglutition wholly, but also to impede respiration and 
threaten asphyxia. Besideti, spontaneous bursting of the abscess may 
take place dunni^^ sleep ; and a conEidemble quaality of pus and blood 
I»a.ssing Eiiddoaly into the gloltia, uiiexifeetedly, may induce spasQjodic 
dyspnceti of the most formidable character, not improbably suffocating 
the patient. To avert sudi paiua and perils, the goieral prineiples of 
Hurgery should be fully carried out; by artificially evacuating the pus, 
BO soon as it has been formed. This may be readily and safely effected 
thus: — The patient, placed before a strong light, is exhorted to gi'eat 
steadineas, Wilh tlie fore-finger of the left h^ind the trjngiie is de- 
pressed, and the mouth opened, so as to e>poK tbe red and prominent 
lunsjl — petbape already oceupjljjg the middle (if the fauecb, and dis- 
placing tho u\'Ti]a, tho ordlnury occupant of thiit gpai^e. A straight 
aharp-pointed bistoury, with \ts back resting on the tongue, is passed 
into the mouth and entered iuto the centre of the swelling, wilh the 
point directed straight backwards, as if with the intention of impinging 
upon the anterior surface of the cervical vtrlebrie; and a pnnctiire 
having thus been made, & Huflitient aperture Ik then established by 
moving the inBtnuncnt with a slight sawing motion. The pu)> eecnpea 



190' ULCEttS OF THE TONSILS- 

upon the ffnigne, and in disi?liarg*^d oitemally. l,nttirti\ movement 
of tlie knife, outwards and backwards, is especiftllj to be avoided; 
otherwise important blood-Tessels are in dtinger — tbe internal carotid 
artery and Ibe internal jugular vein posteriorly, and the common 
trunk <if tbe Temporal and internal maxillary arleriea an tlie external 
tispci:t, 

A cbronio sfjige is not nnfreqnent, in whieb the tonsil remains 
svollen» painfid and stationary; nffordiii^ no si^i either of receesion, 
by resuliitian, or of udvancement by auppnration. Sncb uncertainty^ 
is beet difl|>elled — and usually at onco — by tbe a}:plicatinn of a blister 
over the pari, bent niii the angle <if the jaw. 

It ia of use to remember, that a patient onco affected by tonsillary 
ftbsj^ehfi is extremely liable io i^turn nf (he ftffefitinUj on the applicatitin 
of comparatively ^lij^ht causes, until the first period of adult aj^e has 
passel ; and Ihen the attacks become leas frequent and severe, at length 
altogether disappearing. 

Ulc^s I if the Tonsils, 

The tonsils are liable to ulceration from oidinary cansea; froTn 
exposure to eold or i\'et, from the irritation of decayed teeth, or from 
the **eutting" of the last grindern. Treatnieul is by touching the 
part occasionally wi[l] nitrate of silver, after removal or mitigation of 
iho cftuae — extraction of the decajed teeth, or scarification of the tense 
gam. 

Other ulcers of the tonsils are of constitutional origin ; connected 
with taint of syhtein, venereal, mereurial, or hilli ; sometimes of 
Becondary^ someliaies of tertiary jiCccKsion ; the local characters of the 
sore varyiijff according to ciri;iLinstani:es — simple, weak, indolent, 
irritable, infiomcil, hlonghin.^, or phagcdwmc. Treatmeut, in aDcb 
cases, ia miiiidy constilutiortal. 

llifperh'opJiif I'J thti Tonsihi. 

In adoleacenifi of weak habit, chronic enlargement of the tonsils is 
very apt to occur, crinnected with a miniir iiiflauiniJit'jry nffection of 
th<J fivucL*8 ; the swollen part partially and sluwly Bubsiding between 
the in Ha minatory attacks, which arc of frequent occurrence ami in- 
duced by flight causes. In such cases, it is not uncommon for the 
tonsils lo become permanently enlarged, by pimple bypertTophy. Bodi 
are, in general, affected ; projecting^ ^ fleshy emineh<;es, into the 
fatices J inierftnjig confiiderably with dt^bitition, f^uniewbat with 
reHpiration, and grently\\itli arlieulation ; often eaiijAJnr^ (Icafncaa, by 
pressure on the EuHtaefiian tidies; and rendering the patient very 
Hiible to acute infiammatory afTeclions of the fauces, on the filigbteat 
PKliosure lo atmospheric incleraenoy or vicissitude. 



J 



HVPKRTROPHY OF THE T0W8ILS. 



191 



I 




F1|. 7». 



In the state of excitement, miM autipblo^^tics arc nec^flsary for a 
few dftp; low die I J aperients, gentle dkpborelice, BUiapiams ur other 
light cmmter'imLatigit. la the indoteat state, it is onr objeot to 
uaend the genenil henJih b^ a 
to&io ayslom of general treatment; 
toobtain gradual Hubmdence of the 
Bwellinga by diecTission; or, this 
failing, to remove the redundant 
texture. As discntients, nitrate 
of Hilver, alum, and iodide uf zinc, 
aw moGt in use ; tke twr> Erst 
rublied on the parts in imbEtance, 
tlie last applied in stronp; snlnlion, 
b^ means uf a hair pencil nr a 
piece of spon^. The constiin- 
lional ireaimt'ni is afl for the 
ntrumoHs uachcsy — » condition 
very mmilar to, if not idpntiL^al 
^vith the state of system found to 
prevail in such patient.^. When 
discussion fLiilSf tiie knife's nse is 
espeiiient; not lo exiirpare the 
glands, bni mtrely lo l^k^- away 
tlie rednndimt nnd projecting parlB, The mnnth IWnp ojiened hpfore 
a strong lii^ht, the prominence of the awclliuf^ is seized firmly by a 
volsella; and by means of this iu^tmnieut the [^rt is mude tense and 
stea'ly, iind bronght more luio tho ecutral spiice. A probe-pointed 
bistonrv is passed into the month, wilh iiK baek resting on the tongue ; 

and ila edge liaving- bctn brought in fon^act with the Imvtr part of ihc 
base of the iiwv]\uig, Nuztion iipward^j in &n«rt4-d by a Kll^ht siLwing 
motion, A siiniLir pnicedure is repeated un ihe opposite hide. Bleed- 
ing ami pain are generally iacoiifiiderable. The raw surfaces griUju- 
late and beat; occasional application of the nitrate of silver being 
inade lif^htly, if need be. It is seldom that reproduction is even 
threatened. 

Or the tonsil-giiillotino may bL- used; on ingeniiiUfi iiifltruiiienl— — 
to be had of the cutler — iidapted for at onee fixing and ri'moving the 
protruding part- The liis]i)nry, however, has this twofold iidvuntage ; 
it is simple, and al\«up at hand. 

Objections have been taki^n to such operationa, on the gruuiul that 
ilryiitfls of the faucea id apt tc follow, witli iiupcrfctt arlicnltttioti ; and 
that BouieEim^H b-W there has seemed to bi^ a certain amount of sexnal 
imiotence indneed. The experience of most surgetins does not tend to 
fiiLstain BUeh objections; at the naiuc time there is no doubt that most 
eaAee of chronic eniargemcnt of the tonsil, in adolescents, can be got 

!■%, Tf. ExdjiloTi of the tou^it^L llip kiiifi' Oinml tin; urong wiiv. 





192 



MALIGNANT DISEASE OF THE TONSILS, 



rid of b^ local discutioTJtB and con stitati anal alterativen, an<l tbat tbere- 
fore operative interference sLould be reBerved wholly for those cases 
which have been found to resist milder meaiis. 

ExLirpiitioa oC the entire tnatil, by ligature, or hy kniTtj — IhB one 
opcrntion very hiiaardimaj the other aoc<>mpliahed with great difficulty 
— is in the present day never contemplated ; being- well superseded by 
the partial removal j'lBt described. 

Malignant DtseasG of the Tonsils. 

Cancerous ulccratiun may extund to tha ton^l from the tongue ; 
or may onginatr* in the gland itsfalf^ The latter event i» rare. 

Carciuoinatons or mednllary tumour may occupy tlie tonsil, as a 
primary di^ose \ but more frequently such enlargement of this part b 
but an extension of malignant disease from the lip or lymphatic: glnndH, 

All fiucli aflFectiona are incurnblu ; and operative intfrference is out 
of iho qiicfitiun^unlcsa^ indeed, ut an adviinoi^d period of the caae 
temporary relief hy bronehotomy be deemed advisable, on account of 
impe tiding asphyiia, 

Le Cut, Mtiiiolre sur rexUrpaOon dfls mn^'gdales J^ulrrln^uses, Joumjil dc Wedecine, 
^■ol. 3i- 77fi5- T^tiiLi Hur 1r rpsn'linn i1*"< flmyt'"!"'^*'' M<-mr diO'Ai'adi'Tnip df Chir., vi>l- 
V. p. \^:y L^^f^[m[^ C'onftidErationfl, tc, eur la Luette, lW\nv Moilkulc, July 1833. 
Watfton, Ltoiiires nn I'raclii* uf Mcdkirm. vut. i. Ijindon^ IW3. AlUo Unnu, ynrgical 
AoAlnaiy of [lead juid Neckt E^Unbuigh, ISIL Harvey an RxcIudd of tha £nLirg«l 
ToDaU, LoDdod, I85a 



I 



193 



CHAPTER XV. 
AFFECTIONa OF THE PHARYNX. 

pharyngitis. 

Tbe infiftinmatory proceaSj affecting the pharynx pre-eirinenUy or 
solely, ia of comparatively rare occurreuce. Moat frequently it is the 
result of a direct ciciLingp cms* ; aa the lodgment of foreign bodies, or 
the contact of acrid B^ilistanci^s, Tlie membrane becomes red and 
Bwollen^ ul firtit dry, afteruardii iifTunling an increased aud perverted 
B«crction ; deglutition ii; difRcnlt and painfitl ; puin ie felt on prcssare 
from nitbont; and ihe ordinary conslitntionfil eympti>m8 attend. Tbe 
affection may Bim[ily resolve; or ulceration may take place in the 
memhratie, with copious purulent dlhcbarge; or the subuiucoiia tissue 
may become the seat of abscess; or by Hubmucoiis deposit of plaatic 
matter, and changE^ of Htmcturu in iLiu mcmbraue iltteli^ cotitruction of 
the pliaryngcal epaco may renult. 



Phar^geal Abacas^ 

When matter lias formed beneath tbe mucous membrane, a Hiictu- 
atlng yet tense MwtUing may be perceived; and deghuUioii becomes 
more and more impeded, according to the increnae of tbe tnmoLir. la 
children the affeclion is apt to simulate croup.* Treatment is by 
early and free evacuation. The ordinary sitG of abscess is on the 
posterior aspect of the pharynx^ ia front of the cervical verlebrie and 
their coverings ; and here cutting instrumenls may be used in all 
EKCurity. If the abscess be large, it ia well to use a trocar and camila; 
IcBt ttie pus, surldcnly escaping in ij^nantity, might endanger snffocation 
by psLHsing into the windpii>e. If opening be delayed, net only are 
risk and inconvenience great by the lar^ aize of the Inroonr; there Ja 
also the same danger from Eudden spontaneous discharge, a^ in abscess 
of the tonsil; besides, the l>ones may be involveJ by a burrowing of 
the matter; and, in the ultimate cicatrization of a large cavity, con- 
tmction and stricture of thu pharynx may result. 

* Vide bfirptlitj Juurunl of Mediul Scioftcc, Augudt 1646, p. 140. Ibid, OcWl^u 
1847, p. 320. Also, Atpcmomlrifl, Eilitu Med. und Surg. Jounul, Aijril ISI^^ 

U 





IW grBiCTCBR OF THE PHAftrwi- 



Strkture of ike Pharynx. 

Simple stricture may be the resiili of simple pbirjTiQ^tia, t-fttudng 
nnictural change in the mucous membrane, vriih urcumulatjan o( 
plafitic depornt in tbe fiabmiiGcra& tissue ; and on the Utter oociirreiK» 
the contruotbfk matnly depends. Or ii may be Ibe conseqnencc 
nlceration of the membraoe^ with or withoat suppuration in the parts 
beneath. The prominent and characteristic symptom it difficulty 
«wallowin^» more especially of solid and imperfectly mafticated food. 
And cerlamiy of the eiistcnce of the chaoge i"? detenniried by ilie um 
of a probang or tnbe, ivLose passage downwarda ia rcriistcd by the coa- 
traeted part. The oidinary site of conlraction is at that j»art of 
cavity which is Datiiraily m^'st narrow — the lowest. 

Malignant contraction \& produced by carcinomatous fonuatioD ut 
ihe muc<ms and snhraueoiis tissmes ; the surface speedily assumes thfl 
tjpen condition, and much iinbeaUhy mairer ia discharged. The symp- 
toiDjj are, great pain tn the affected part, incrcof^ed by motion and 
predsnre ; especloralion of fa^tid, copicjiu^ bloody discharge; great and 
increasing difficulty in swallowing; gra^Imd vasting of the frame, 
l*ttrdy by inanition, parfly by progress of the usnal malignant cachexy. 

The simple siricliire ia trealc<l by dilatation. A probang — a 
rounded piece of wbalelione, T\'ich a bulbons extremity made of ivory — 
^ell oiled, i» parsed gently doivn to the ub^tnictioD ; or a gnm-elostic 
boii^e may be iiw*(i for the same purpose. One having been selected 
of such a size as nill pat.s without the use of force, it is lodged in the 
contracted part, and reiained there for Bome lime — according to the 
BensationB of llie paiient. After a day or two, the irritation caused by 
Ihc former inHtnimcnt having siibeilded^ anntLcri a fiize larger, ia Gioii- 

larly employcrl. And lime, ^ndnally, ihe normal cjdibre ia restored. 
.\n ine;lrnmeiit of fnll Mze sbdiild b^ passed ocCfLNionallVj ho^rever, for 
wnie lime afierwjirtls, to obviate Ibc leudency to recontraction which 
exists ill all Tiincous canals ao aflecled. The object of the passing of 
iuBtmnients is^ not to excite inflammation or nlceration in the con- 
iracted iiari ; for this uould plainly tend to nliimate aggravalian of 
llio mtjrbid statt' ; but to cKoile nhsorjition of the fflibmucona depoait, 
and A reHohilory pRieosa, ivilh diw^har^, in the membrano itself. At 
the Hauio time, f^omti benefit is also obtaine<l by mechanical dilatation. 
The nialigmud HlnMnrc aclmits unly of palliation. Great atlentiou 
IB p*id to tbo a<l[niijiKliali(>n of nutritive ingeani, bo as to husband the 
frtUiii^'Hlratigih i whili? ptiiu and discomfort are assuaged by opiatca, 

Pirtrel intt^rfcrojicn willi IIjl- pnrt, by means of bougies, \jx olberwise, 
^with dibilulirJN \\\ view, cji^iu.t but do hnrm. Often, however, the 
pain "{ tini nlr^criiti'if Hinfaoc may be relieved, by occasionally louchmg 
it with a wdntioji u\ 1lju nilralo of edver. 



BAUCULATED I'nARYN^. 



195 



Spmm of the Pharynx, 

In ptttientB of nervous temperament, prone to hysJejJa, with 
Blomncb &nd bowels dlKurdered, spnstEi of the muscles of die pharynx 
Is not ail inifreqiieiii oocurrence ; causing pain in the part with aa 
ucGo^y and apprehensive fading of lighlncHS, and materially interfering 
with Jt'glntition, Tbe aLlacka are only oecasioiinl, Bn<lc]en in ncceesion, 
and ^rnduul in reiuifisiun. The treatment is mainly countitiitiona] ; of 
an alterative, tonic, and antiapoeniodic ehajacter. Locally, extemni 
couDter-irritatton of a alight grade, or opiate frictJoiiT or a belladonna 
plairter over the nape of the neck, may be of service. Somt'times even 
the paEaing of ihe probang will not convince Lhe hyHtcrial p^ilicnt that 
the affection ia merely nervous. 



» 



Fartilt/^is ofUie Pharynx. 

This, occurring in the aequel of any diseaae, is usually of very 
unfavourable impirt; denoiing flfTcctioa cjf the brai^, probably by 
cfiupion, which ia likely lo prove futHL It mity occur singly, liuwever ; 
OH afler external injury of the head or neck ; and then the jirognosia 
may be wimewhat more hopefuK The pronjinent fijinptom ia eioipte 
dysphagia ; without obslniction to instrunienls, or any other sign of 
BlriL'ture in the pDsaa^- Treatment is to be directed mainly lo the 
head and neck, by coimler- irritation and such internal remedies as may 
Bccm advisable ; vliilc hfo ts mLUn^rbilo BiiataJncd by supplying the 
Btomaeh with nutritive Huids, by means of a tubu ptLSsed into the 
Desoi>]nL^i?. 

SiiccuhtUd Phurt/n^. 

Sometimes the lower part of the pharynx becomes dilated iitto a 
poach, of greater or less eizo, rituate immediately behind the (Esoplia- 
geal orifice. Foiwl lofl^jes there, Bometimes fur many hours, eoming 
up a^ain in a kind of rumination. Deghuition is diflicidt and imper- 
fect; often accompanied, e^ijMJcially when liqnidB are takeEi, with a 
churning noise. Frequently, too, there ia a copious Eccreiton of glairy 
mucus; sometimes ficcnmulating sjjonlaneously in the mouUi, more 
commonly brought up by hawking. The affection plainly adioila of 
no direct treatment ; and care must he taken in nsiug the prohang— 
should that be thought neeesstiry for an exact dia^iosis — lest it should 
enter the puuch, and be forcibly impelled thence through the parietes. 



Tttmaun of tht Plutr^nx^ 

Tumonrs occa^^iorally, though rarely, form io the pharynx. They 
are troublesome hy the dysphagia which their bulk necessarily ucca- 
mona, and dangerous by the tendency which ail tumours have lo 






FOREIGN BOIUES IN THE PHAUYNX. 

enlar^ineot and degeneration. Tliey may b« Blmple, and of Ibe 
polypous cb[inicter ; and ihcAG iiiAy be detacbcd l>y ligaturei apjillvd 
lo thoir base by toeanB of a double onniila. Or ihey are medullary; 
oud then IrrE^mcdiable. 

Foreign Bodies in the Pharj/n^c. 

Porliona of food, and otUer arlicica held in tbe moullif Dot dd- 
frDi)ncnUy become arresCi^d in their pnaeagG downwards; even ihoug*!! 
no abnormal contractii.>n esist at any part of tbe canal, Subslftncea of 
some BJze and solidity are likely lo rest at the narrowest — ibe lowest 
— part of tbe pharynx. Those of a slim and apkulated character, on 
the contrary — as needles, pins, fish bones, pigeon bones, &c. — are 
more frequetilly entanglud in lUt folda uf the tiuft p^dtolCi In both 
situations, the foreign matter la ■within r^ach of the fin^^r ; and thitt 
is the beat instrument by whir^h to aKcert^tin the esact Bite and nature 
of the Iwltimenl — as well a^ the best ^lide to the forceps in extraction* 
Even a uiiniit« snhstance entangled in the fauceH cau^s much distom- 
fort; and bc^des, if nat removed, will probably induce a certain 
amount of tlie inii:immatofy pfoi.<?ss^ But ihu larger and solid sub- 
BtanccG, lod^'od lowi^r down, call more urgcnlly for our aid j ioEiEniuoh 
aa bv their bulk and pri?sftnrfi^ and by the hpanmudic niovementa which 
their irritatiou mduccH in the larynx, they threaten Biiffotation. 

The patient ifi seated firmly on ach;iir; tiie fore^finger is thru&t 
determinedly into Ifie fauces; anil iis point is nioved about in every 
direction, until either ihe fon-rj^n Mdisianee h diseovereil, or ibe jnirijeon 
ia Bali-jfiud tliftt th^re is pn fjrei^ bndy ihere. Miieh retching- will La 
occ/iKifmeil in nil probability ; but this nmst \tQ nnhpeded bj the 
examiner, and endured by the patient; perquisition of the soft palats 
being got over as speedily as possible, ms the extr<?mities of the nerves 
concerned in tha pr<Mluction of vomiting arc cbietly situiited there. 
Tie [jrescnuii and sllu of the fur<.'ii^n body having betn ascertained, it 
Lr eeiEcd by forceps, and gcnlly withdmwn. Far yln^ and Kuiall 
bones in ihe arches of the vi^Iuiu, the ordinary drcnning forceps, or 
merely the finger-nail, will mifHce. For solid mutler lodged lower 
down, longer fmceps, p;ently curved at the estromily, are more sidtabUp 

It is important to remember that very frequeiitly the painful sen- 
Katiua of a forvigii body lodgi^d in the pharynx remains, afler the 
flubRlancc iinelf h*ia pnsBcd down into ibf* stomach. When, tlierefore, 
we have made a careful exnmination of the parts^ and sati^lied oiir- 
Bclves that no foreign body ia tliere, we treat snch abnormal seiisation 
by leecbingi followed by counter-irritation, or by anodyne embro- 
carion. 

Thf! parsing of Instrumenh hif Utt Pliar^nx. 

The snrgeon u not i[afrer[nently called u^ion lo pafcs instmmenl& 




THE PASSING OF INSTRUMENTS liV THE PHAKVKJC, 



197 



inlo the pharjnx and teeopliftgiia ; curved forcepa for the extracHon 
of foreign bodies ; probangs and Ijougit^g far the pmpnlsii^ri of impacted 
articles of fixxt or for the relief of simple orgTinic stricture ; hollow 
tubeH for the conveyance of nourishment into the stuuiuoh, in ea^es of 
wound of iLe pharynx or resophagiia — aa in cut throat; and the tube 
of the stoniuch pump, in cAses of poisoning'. Tbe points to he attended 
to are; — to use all gcnllcnees, 60 as to avoid leeiyn of the lining- 
metntjrane of the canal ; and to tako egpecial ears, purtioulurly ivlien 
it is our object to throw in jjigesta, that the tu>rtj does not paaa into 
tbe air p'>nsa^. If the patient be sensible, he is st^atud on a ch^r, 
with the he^id ihroivn much back^ so as lo bring the tapper part of the 
alimentary t-anal into us strait^dii a line aa possible. The mouth havitij 
been opened wi-le^ and the tongiic depressed with ihi: left fore-finger, the 
tube i* mov^d mpiilly ya^i the si>ft palate, sfi iiA to avciid retching- ; and 
its extremity is then ^ntly propelled, resting on the posterior part of 
the pharrnx and made to gplide, as it were, on the anterior surfaces of 
tbe vortehrffi in its passage downwards. ^Vhe^ the iostniment's point 
is opposite tbe rima glottidts, the patient is directed to utake an eSbrt 
to swidlow his saliva; or, with the [eft hand, the surgeon raiaea the 
boT of tbe larynxj and at the same time pnlla it gently forwards from 
the tcsophagus; eiich movement being- plainly condueive to the free 
passage of the inalrnment into the latter canal. When insensibility 
exists, the operation is in one way facilitated; inasmuch as there 
is DO resistjmce on the part of the patient. Bnt, m fiuch cagea, it ia 
plain that our care to insure a rijLjht paeflui^t for tbe instrviment 
must he doubly ejte^ted - the patient having no power to warn ub of a 
threatened deviation from the proper track. In most cases, it is well 
to assure ourselves fully thai the tube is in the ceBOpbagne, and not in 
the larynx, before fiuids are passed downwards to the stomach. Fop 
this purpise, a sheet of paper may be placed nver the face, with the 
extremity of the tube projecling through it ? while in front fjf the lube 
a lighted taper ia piit, whicdi by the paper ia effectually screened 
from the flatus of the nostrils in expirHtion. If, on expiration, the 
flame remain steady, no air impinging on it, i\e may proceed with 
injection ; tbe tube ia certainly in its right place. If the flame be 
extjnguished, or even made to bend considerably, it is equally plain 
that an errur ban beeu made ; and that injection would almost cer- 
tainly occasion Tatsd Qsphyxia, It ia iK>Bsiljl<!, however, th*tl the flama 
may be affected a Uttle in expiration, although the tube be qnite in its 
right track- For, it is probable that in inspiration a certain amount 
of air may pass downwards by the tube, which during eipiralion may 
be again extruded. 

It is well to remember bow a large instmment is preferable, in 
such cnfes, tct one of email size; huing much leas lively to enter the 
windpipe. And it is also worthy of note, how, jn emergencies, a 
syriDga ia not essential to effect clearance of the stomach ; a tuhe 





193 



USE OF THE STOMACH TUMP. 



having been passed, tbo fluid oont^Dts of the GtoiDach ma,j ]>e made tol 
flow out by it, on nierely bending ihe bwly, and bringing the muuliil 
to a losver level Ihan that of the ejiigaBtnum. Wheu a Hjniige iB 
employed, it plaould ahvayii be with caution ; olberwiee, cc^shymoKa 
and I.iceration of tlje g;£i6Lnc tqucouh meinhMihe are not improbable. 

Also, unless previouGly aware that iho Gttunach contaios much 
fluid, it is prudent to begin the operation by injecllng tepid water, 
■which IB afterguards pumped out along with the previous ccntente; 
and this iujecting and tjeciiiig may be repeiited as oiien as may beem 
uoeeseary, with the do«bl<; view of washing' out the viscua thorongblj, 
and at the Kama time avuiding injury to the lining memhraoe. 

WatAon^ ClM^cnl Lrclure, &lcd. Ga^cllE, vol. xvii. Kunzt, Comnicnttfia Falludiw 
^u cte DyBphif^n, Lips, imo, SloDTDf on tbfl Morbid AiiJtlL:km^ of tlio Gullpt, BdiiL. 
1S30. C. BdU lOdtitkilGa of tiurgeiy, roL L Appia, da StrictLLria (Efiophflgiii^ Hniddb. 



19& 



CHAPTER XVL 

AFFECTIONS OF THE (ESOPHAGUS. 

Stricture of ihf. (Eeophagua. 

(EBOpnACmS| of a moat inletiflo cliaracter, is occasionally induced by 
the swallowing of acrid fluiik; aB ficalding waler, the nitric or 
Biilpbnric ftcids, s^^iap 1c*?b, cftustio alkalieSj kd. A more modcmte 
affection may h& induced by slighur causes, or may occur when no 
c&u£e can readily be assigned ; and its probable result n^ill be cuntrac- 
tJon of the ottiiul, partly by change of tlie mnuoua membrane, partly 
ftnd mainly by snbraacous ilejKJeil, 

Bnt contTJiction of the fnaophiLgnB may be of Lbree Itindu, as in the 
cftfie of the phEirynx, It may depend on spasm ; of suddeQ accession, 
and only occasional ; removable by general 
traatmeat Or it may be the result of a 
clironic inflammatory procesa ; of gradual 
approacli, conetant, and curable otdy by a 
eantioijR iiw of tho pimple probang or 
bougie. Or it may l>e causeil by fitrtic- 
tural change of a malignnnt kind, followed 
speedily by ulceration, and capable only 
of palliation. 

The flimpb organic stricture ia of intwt 
frequent occurrence. Its ordinary site is 
at the narrowest part of the canal ; oppo- 
site the cricoid cartilage. When light, 
and of considerable duration, the tube is 
prone to become dilated ab<'ve the alric- 
tnrpd part, forming a |>onch in which foi>d 
ineonveniertly a«einnulatea. The cnn- 
strictors of the pharynx are usually hyper- 
trophied ; and the upper cornua of ihe 
tt3T'oid cartilage may become ctoeely 
approximated.* Above the Blriclura, too, 
iiloeratioa ia apt to take plAco ; whiclj, though not malignaat, is nevor- 

• Luicet, Ko. 1209. p. 483. 

Fijf. 71'- SiricCiire of the ^llct> at it* moat ordinary ailc, Abouicic ehflWiiintiwluAi'l 
b]r tht uimitti. 




I-V7W- 



200 TOREIGN BODIES IK TBE ffiSOPHAGUS- 

th«levi very intractable, and most tnconveDieittly complicates the case, 
Bemdes, in consequence of obstnictioD to deglutition, the syBtem ia apt 
to siifler more or ht^ by an apimmch to iDanititiu ; acjd tliercfure, it ia 
obvioualj our 6niy (o commcnoo the Euitablo remcilial intorfercDco at 
as early -i period as possible. In usbg tbe bougie, even more gentle- 
ness and care, if possible, are expedient, tbjin in the casr of 5tric(iired 
pharynx; force h«ing more bkely to produce lesion of tbe membrane, 
and even to cause perforation of the tul>e- It has happened that the 
head of a probang, supjioaed to liave pussed on to tbe btomach afltr 
having overcome the Htriohire, bn* been found, after JcaLb — al no dis- 
tiuit date, and not nnoonnecte<l with the event — (o have lo'Jge*^ in the 
me*liastiaum 1 Another precaution is efnially nece^ary ; namely, to 
beware that there is no error in our diagnosis; to be certain that the 
contraction is really caused liy structural change in the ccsophagna 
itttelf, and not r1e[)endeiLl on th« pressure of ru anearisniBil or other 
tumour. It is easy to understand bow tbe tiirnst and prceeuro of iv 
ptobang or lube, acting on the parietee of an advancing aneiinRm, 
may fearfully accelerate the fatal issue. 

Foreign Bodits in the (Esophagus, 

Torcign bodies, ivbetber obtitsc and globular, or sharp &nd angular 
— |>ortions of meat, or Ixinea, pins, Ac, — iM'Oome nrre^ted n^tially at 
tbo QiUToweEt pari of tbe canal, nesLrly oppt)site the cricoid cartilage. 
Or, Icxlgirig there in tlie firnt instaiicCj they become displaced either 
npwurdfl or dowm^-ards — usually in t)ie latter din-ctiou — by tbe efforbi 
either of the iiatitnt or of those ^hom he calls to his aid. Tbe result 
variiB, ftCL-ordiiig to circumstancee. There may be bimply tai irritation 
prv^diiccil by the presenc^e nf it foreign lK>.ly, wilh more or lees dys- 
pbagia; or an inllamuialory process is kindled, and advances perhaps 
to 8uppura(ion aud u lee ration ; or by tbe pressure and irritalton of 
a bulky suhslanee, life may be immediately perilled by impending 
nf*phyxia. Or, as ver>- frequently bappena, tlie foreign body sl^ 
down into Llio sUmineh ; leaving, however, a marked bcu^tJon of ilo 
prcwnco at tfm nite of ils lon]|H^rary arrest, 

Tbo pTOTieucv cif fii^'imi niullcr is aseertained by the bent forcepe, 
or by (he iindimi^f ; jtawied carofnlly down, and moved gently. Accoid- 
in|f lo Hie iiniuw of ilii.* ^ubatance, either extraction or propulsion « 
prat^iiw^'I, II tlio obstnieling Uxly be a piece of meat, or other article 
of HuhI, not likely u» hyiiro the canal in a forced passap:e, and capable 
<Tf U'iiitf «uh»"*i[iuinlly Jigi-Rtod \a tbe stomwh, it is the simpler pt»o- 
liee — ami iierWdy warraniablo — lo push the foreign siibfilftn«» g«fitl]r 
(lowriWiird* \>y means of the probang. T\Tien, bowever, the circom- 
stAiavs arv of an op^>o*iito chanitier — a^ usnally happens; when »e 
■Tfl BatjnIliHl lh»1 ihr ivNopliagiis cannot fail to euBlain legion in Jitlcspts 
at propnlHJon, and Hint the slomacb will be miable to make a&y »t>»- 



rORElON BOOrES IN THE tEEOPEIACirB. 



201 



factory impression on the enbetance, should it be received there, ex- 
traction ia invariably to be preferreJ, Long, curved forceps are the 
most generally available instrnment ; the surgeon being provided with 
Iwo pair£, of opposite movements in the hladee. The one baving miased 
LLc foreign oubatiiDcef when this is narrow, ur flitt, the other can sctirc^lj 





Pig, so. 



Pff- SI. 



fail to eeiae it. Seizure bavin^ been made, dislodgmenl from the 
parietofl of the ciinfll is t-j be effected, hy a. timtiona uiiggling move- 
ment of tbe Imnil, before extraptive power is nppliejl ; to avoid untie- 
ccBBary injury of the parU, Needles or pins may be entangled in 

Fig, 80, Forcepn for entractjiiy foreign bodi« frnm the pliaryns nnd itnoplapn, 
Fl^. St. The componiaD Turc^pB to ¥\g. 80; opening in the oppoaitc direcrion. 



202 fflaoPHAOOTOMY, 

loops of tlirea^l uttrtcheil t> the enil of b. jnece of wbHlebone; pnHKe*! 
rlnwii Ui tbo sit* of lodgment, and movej gisjilly about. Flat Biib- 
utaiicuB, such as coins, (Jresoixting Iheir edges to the operator, may be 
brutigUl n\j by ^L flat and brotwl bhml hook, Whe» no uibtrument is 
at buiidf and tho case is urg^nt^ c^trugiijD of the forel^ BubBtiince may 
ba effected by esciting vomiLin*:; and this may be doua either by 
administration of the ordinary emetics, if swallowing' be at all practi- 
cable, (if by meebanicftliy tickling tbe fauces. 

Whan indigesUble Bubslances hnve passed into the stomach, they 
uauifclly fiiiU ibeir way to thu hiirfiiL-t', by thi? iiHiural outlet — jjer iLiium ; 
passing off with tlio fooiOeiit umlter — ufton bvit little changed — ftfler 
the InpBO of some time. To assist tbe downward movement, purga- 
tives ar« often employe^]. If the foreign body be solid and obtuse, no 
harm is doue, ami eitnision will pTobubly be exiwilited. But if the 
Hiibslanco bo sbiirp and spieulAted, the practice cannot but be mis- 
chievous; lending lo proiluce enmugleiuent in the mucons membrane, 
probably with jicrforntion of iho bowel; p-nd also tending to kindle 
influinmatiifU in iho n.tr»?iited part. In such cases, therefore, it is more 
prudont ^) await tbe working i}f Nature. Needli's and pins usually do 
perforate the intestinal canal ; but, if left to themselves, the proceas Is 
gradual, accompanied by protet^tive pbistic exudation, and consequently 
hiirmlesn. In doe time, the foreign budy a}>])eare at the surface, as if 
8oli<?iting extraction — perhaps months after the dato of i\s enlTuiico, 
and aflfr having traversed a mr^st circiulons route. Fish-bonps, and 
l»nes of rabbits or oilier small i^nimalE, are not mifrequently arrested 
by tlio spbincier of the auus, after having' f^afely made the parage 
above; and may reiiuire Iho use of both knife and forceps for their 
reaiovab Cherry stunea, and sn^h like siibsEanees, may lodge in the 
vDrtniform process of the caput cn^cnm, and excite either abscess there 
OP general [writ^initis. 

Occjisinnally, lbi.iu*^li rarely, it happenis that the foreign body wiJl 
move neitlier up nor down in tbe ncsophagus. Extrustcn and pro- 
pulsion hanng iH'tb failed, excision is the only other resource. The 
Hubstanee is ent down u[>on from withnnl, and extracted through the 
wound. 

Tbe neck is slrtHcbed, by elevating and throwing back the bead; 
and, by Ilio fingers of an assistant, the foreign substance is made to 
projt'ot aa much as possible on the left side of the trachea, A free 
imision is mude over the swelling, tbtongh the ekin and ^datysma 
myoidoH : aitd tbtn by h cantioufl and laoro limited use of tbo knife, 
the rt'Wkpbasiw is exjiosed in iis mo&t projectmg part. Here it i*t 
iK-netraled by lh« knife ; and the opening thus formed is afterwards 
dilated to a Hnfficient extent, partly by the finger^ partly by slight 
l^mchea of tbe knifeV edge. The offending matter is laid hold of, 




FALBY OF TEE CEaOFHAGUB. 



2on 



hy tbe finger or by foroops, and removed, IlemorrlirigG hnving 
been arreted, ihe wound \a brought accurately into appf^Hition, and 
treated for adbesion. For Bome <)Bja & tube is worn, passed by tbe 
mouth ; and through thia tho necessary nomTHbinent is conveyed, clear 
of the wound. 

Tl mnj be imagiueil th&t forei^Ti anU'ita.ntePi tnity bu safely left to 
li30E«n thcmaclvfa by suppuration, and bo to fikcilitatOj if not cificct, 
their own eitniwon. But esjierience declarfs that it iH not bo. The 
obstnicliun to deglutition, and impediment to breiithing, are them- 
eelves circumfilaoces HUfGtiently untoward to dctnand prompt inter- 
ference. The inflammatory procesBj 100, which i& sure to follow, ih 
fraught w jib both diaudvuilagi; and danger; it may luy thfi founda- 
tion of a formidable organic; etrictore; it may cauto a troublesome 

abscess, resitlling parhape in a Jintulous opening* in the canal ; or, in a 
low site, nlceratiou msy open into tbe arch of the aorta, and prove 
^eedily fatal. 

Pais^^ of the CEsopfiagus. 

e Thin, like tbe corroeponding affection of the pharynx, ia naually of 
vil imjiort; betokening diseawi of tha ncrvoiip centre. Inability to 
swallow may be complete; but the probanp meelB no obstmction. 

In Rome cases benefit may be derived from counter- irritation and 
Uflo of galvanisin ; bat in most we must be contented with palliatioD 
— BaetaJning life by matters introduced by meajiH of the Ktomaeh pump, 
OB well ofl by nutrient cntmata. 



Huiize> C^ommc-TilAtio PjittioLojH<^A cle DysphagiB, Upa. 1S20. Monro, on the llorljid 
AnAlomy of Che UuUet, Edin. Ift.'K). C. Bell, liiiitHu(«A cif Sur^Rry, voL i. ; AmoU. on 
CEoopba^mpy, Mod. Chlr. Trw, toL xx. A|ipiH, dt Slrlcluriit <BHU|»h]if^ JftidelliL 



204 



CHAPTER XVIL 



AFFECTIONS OF THE EAR. 

Foreign Bodie9* 

Children are apt to InBert forei^ mailer into tlie me^tiis at^di- 
Lorius, as well as into the noslrila. Disloilgment hiiJ extriwian are 
effected \ty tlie same means; by the strtftm of wutcr injected; or by 
the iis€ of a flat und bont probe, or cnretLe. FtircepH are a still more 
repriihensible inslnimcnt here, than la the case of the nostril; for 
impaction is not only more probaWe, hut likely to he followed by 
much more Beriout* results, Abjrtive attempts U> dislodge, by forcepa, 
have occasioned deeper entratice, disruption of the ioternal car, intense 
otitis, and dcjtlb,* 

Larvffi hnve lodged in the ear ; causing sevfre inflftmrnation there, 
mth miicli local sufferin^^, and o;rave const itiUional disturbance. White 
precipitate, BUf^pended in niilk, when injected, ia found snocessful 
in killing the animals ; and they may be subsequently removed by 
forceps, curette, or a stream of water,-]' 



Polypus of the Ear. 

Two forms of Polypi may form nn die lining membrane of tbe 
meatus externns — iiannlly from that middle part of the luealus which 
furnishes the cernmen ; one soft and pulpy, iinalogous to the common 
mucrtus po^ypiia of the nose ; the other mure firm anil flpHliy, resem- 
bling rather the tiolld }xjlypi of the ntenis ; both fiimpie iu stmcturo 
and tendency. Deafneas is occasioned, along witL uncomfortable 
RenBations in the part; and more or less dischargee Cficapes, of a pari- 
form and offensive chariicten Treatment is by evidsion ■ slim forceps 
being employed for this puqiose, as in the case of nasal polypus. By 
the use of tlje ear-specohim, caiitiooaiy introduced — an instniment 
similar to the nasal ^tpeciduin^ only of a more tubular extremity, suited 
to the ca\ity wHoh it is intended to explore — the site of growth is 
ascertained ; there the seizure by forceps is made ; and, by slight lor- 
fcioD combined with evulsion, extirpalion ia effected. Or the attucb- 
ment may be divided by means of blunt-pointed scissors. When the 

• lancet, So. 10G3, p, 458. + !hid. No. 1;H4, p. 688. 





OTITIS- 205 

growth spriiigB from near the raemLrano tympani, however, evulsion ib 

iiul »nf<; ; futU it its better tu destroy it Ly caiiatlc — Buc;h na the [HitusHU 
cum calci?.* Whi*n bleeding bus ceased and pain subsided — after tba 
HJK? i»f furcepB i>r acisBurs — it ia well tu toiicii the part wilh nitrate af 
tiilver, so iui to diminish tbu clirtnce of reproduction. And if the mar- 
bid structure should not haw bven eolirely removed, eucIl cauteriza- 
tion mny require repetition frtim time to time- During the healing 
pjuirran, rdaXHtiuii of the meiubnuie, ^ith copious diguhari^, la apt to 
prove tTaubloBumc ; demanding the duily and repoat*Ml use of gently 
H[imiibLt[ng' and imtriagent mjections. 

Fuiiijoid j,TamilaliuTiB, of a polypous character, not unTroqiieutly 
Bprin^ from tlie membrane of the me&tns, in ea&ca of loug-cimlinutd 
wtorrhoea. They prow from the lower part of the tube, or from the 

membraiia tympani iLeelf ; and nhtti of lar^e size may Bimidate poly- 
pus. They are got rid of by nitrate of silver, used eschiirotietilly, luid 
by tLe Bub&equent employment of astringent iEJceltunfl. 

Olttls. 

The iiiflammi^tory process may attaok the mucous membraae of 
the ear, and texturofi conneoreJ tlierevrjlh, either on the exterior or on 
the internal aspect of the mcmhrana tympani. In the one case the 
affection is said to be external ; in the oilier, internal. 

External Otitis. — Tliis most freqneiAtly otcurs in the young; the 
result of exposure to cold, with or without irritation caused by affec- 
tions of the tt^ib or guuis. It conslitutea the CL>nimon earache, from 
cold; the pain being that whicb attends on the ordinary inflammatory 
proceKH, occurring in a ]iiLrl of estreme FiefisitiveneKH. Tlie affection 
may simply resolve ; or it may causo a piiriform exhalation from the 
membrane ; or abscess may form benealb the membrane, poJnling, dia- 
charing, and causing mncli aggravation of diBtreas, Treatment is 
eimpty antipiilogistic ; leecliing behind ibe ear, fomentation, hot poul- 
ticts, pnrgi^a, and antimony. When abscess forma, activity in tho 
application of heat and moisture is redoubled; and as soon as tit e ap- 
pearance of matter is presented, evaeualion is effected by puncture. 

Intitrnat Otitis is a more Heroua aSeelion ; and may be variously 
induced; by injury, exposure to cold, or extension of a more outward 
aLluck. I'ain may not be more acute, but is deef^r seated and more 
intolerable; attended uith throbbing, and confusion of the head; tho 
ayatem flympaihi/ing in well marked inflammatory fever. If the pr*j- 
cens advance to suppuration, dianiption of the internal ear, with loss of 
bearing, is all but inevitable ; and very probably a still mnre strinus 
result may entiue, namely, affection of the interior of the cranium* 
Treatment is actively aatlphbigi^Lic. When ctrlAin that aeute intoraul 
' ToiNDER, MeLlical Tini?a and GuetUt Jan. ^ 1^2. 





208 OTORRU<EA, 

otitis exists, wc will not content oursel7es wilh leeching^ bpbincl the 
ew; but may take UuoJ Ixith from llie part and tri^nn the system, 
Calotuel fLud opliinij {ooj will be ndminiBtered; tbe invasion of an 
orgnn of delicate tesiure* of important function, and in near connexion 
willi the brmn, being siifliuient uarrajtt for sudi procedure. la sbort, 
the bodt eOurEfl will be made earlj and salii^Pnclorily to £iil>due tbe 
rising process, m as tii preveiU snppnnition if jiisi^ililp. Wlien mntter 
has fi>rmcd in the cavity of the tynipamim, tlic membrano lympuni acta 
injuriously ly repressing onlward diacbarge of tbe abscess \ occasioning 
teusion, willi aggravaiion of the wytnplonis. Here the general mlefirf" 
Surgery are to be fulGlletl j by incitflu,^' ihe tense, resisting membrane 
— ffbicli \a seen white and promint-'nt — bo soon b-h we arc satisfied, by 
its cliange of cobnir and form, and tbe conrse of the general R\mp- 
tuinH^ that intra 'tympanal »ii[ipn ration haa talion place. Tbe membrane 
mnet yield nitimaiely, by nlceratiim or sloughing; probably too late 
lo save the delicate and complicated apparatus <»f hearing from irrepar- 
able injury ; perhaps too late to prevent extension of aggravated inflam- 
matory diet^asc to the limin or its mciubranes. 

Chronic Inlernsd MiitiR in common; h"S8 rnnnidable than the acute 
form at the tinii: of invaj^ion, but ^ironp, if unchecked, to lead to e<]iJalIy 
Rcrimis conwqnences. 1'he membrane may bo Biinplj changed in 
structure; Ihict, mu^h, and vascular; clogging and enveloping the 
ostricula audilus. Or fiuppnraiion may take place, with perforation of 
the membranai and pi^bjibly with idtimate net^roaifl and discharge 4^ 
the ossreuln. Trualment consititR in attention to the general health, 
alteraiived, and patient con nlcr- irritation, 

Oiorrficna. 

By this term is understood a jmnfortu or purident diwrharge from 
the ear; the reRult of d^ronic inflammatory diseafie, Ufiually it ifl 
preceiled by the ordinary aigns of an tttt^wk of olitiq, HcntpT fr Hfjbacute 
in ciiaracler. rhildreti are moHi li:dil« to Ibis aiFccfion ; and especially 
those of sirnmons habit. Often it is one of th*r seiiuplai of scarbitina. 
It 19 well lo examine the mciitua atleriiively, by means of the speculum, 
discharge having been previoTibly n-inovcd by gentle nbluiiom For 
if the mflmhmiia tynijiani he found entire, and loleral»ly sound, tha 
ftflFflCtir»n Is no declaiwl to he compani lively ainiide ; whereas, if (hat 
membrane be fomid imperfect, denoting an ijjternnl ori^itL of the eup- 
puratiiiu, prognosis is rendcivd m*ire guarded and nnikvourable. 

It miTst nevtiT be forgoUen tluil the term Uturrhtea, in truth, com- 
prehends many ;iOi'Clionn ; iuflammalion tit the external ear, of the 
cavity of the tympanum, or uf the uin-itoiil eellS' And it ie cipmlly 
imporlani to obpiervo ihnl ioflAmmafTon, l>egnn in the exiemal meatUH, 
may at any time extend lo the other parls, hud thence lo the contenla 



OTOHliHCEA. 



207 



of the cranium ; from the tympanum to the cerebnmi, and from the 
miistoit] cell a to ihe cerebeUum.* 

Treatment in mainly jiaHJatiTG and expectant, as regards tLe part; 
re»turative or regards the system. The cuDBtitutional cucboxy is to 
be conibiLlcil by ihe ueutil meanB* Tbe ear is kept clean by fn-quent 
and carvAil use nf tepid water, ^itboiit aud witLm the loeatiiH. The 
State of die month i* lonbi^ to ; an*!, if need be, amended. Re-accea- 
aona of inflammatory diseafie arc avtjrted or unbdueJ, by occasional 
leecliiiig' and fomentation, as circumslantes may require. The chruiiic 
affection, which ia maintaining tbe etruclural and fimolional disorder of 
the muuomi membrane, is eougbl to Ije overuiine by carefnl counter- 
irritalion — hocU oq blislering btjhind iho ear ; thia, huwover, being pro- 
ceedpd with cautiously, lent enlargement of the glands of the neck, 
which frequently is an accompaniment of otorrbcoa, sliouJd be eitber 
inducted or ag^ravuled. When m^arly all the sytnpioma of inflam- 
matory diseaso ir the part have BUbsidcd, and when the general nystem 
boa decidedly improved, weak ofitringeula may be employed, to fuvour 
recovery of the membrane, and cooEeqtienl ceEsation of the discbargo- 
TJiifl part of the Ireattiient, buwever, must always he eondntted with 
the greatest possible care; leet, by sudden arrest of the discharge 
return of the inflammatory attack, in a deeper site, anil in an aggra- 
vated form, ehonld unhappily ensue, Sncb risk ia in all casva great, 
when sudden arrest of discharge bus occnrred, from biiy uaiiee; but 
eepocially in thoee vaacs in whit^h iniplicatinn of the interjial car ia 
indicatert, by imperFectiou of the membrnMa tympani, and perhaps 
prevIouB discharge of the OBsicula auditus-'j' 

Olorrhtna in the aduU may bo couufcted with tte lodgment of 
foreign matter in the meatM, long overlooked. A graha-aoed, or such 
like Biibfelance, luay be eAlruiled afiur many ytara ; olorrliiea — occa- 
Bional or cojistant — Iiaving hcan maintained during the whole periud 
of its residence. 

Olorrh-ea ta oeciisionally connected with a deprenerated condition 
of llie pars pelrosa of the lempi>ral bone; vhJch has softened, and 
become converted into a medullary mass. The symptoms are cerebral 
and obncnre. TJje iat^ue is bop^iletis. And it U very jdain thai llie 
fatal event would cerininly bo mucli accelerated by asueceaaful attempt 
to arrest the aural discharfre. 



* 'NopVTsOQ aolferitijf from chronic catarrhal infUmmalioD of the dermoid Iiyer of 
Cbu rn^atim, iJii" nicmbrmia tA-mimni, ht of the niiiL^ouE mombnini- of On- ryrnjumiim, flio 
tw oanumL that i^^fue is not Ix^wtg firoLoTi|^u] tu tlit lempoTol Iiodb, Iht liriiin, iiiiil its 
membmntfl ; ind tliat any uTdlnBry cxcilin^ i,'au#r, in an attack of Itvsr or 'laAu^ati, a 
IpIqw on ihc head, ^v^ may xtot iarlii<:e the uppcarancc uf ucntc sjniploine, whjuti, oa a 
fttnend mte, flm apee^lily fnial,"— Totsbeb:, Med- Chir. Trun*. vol, JtXJtiv- 

f Ad juiulrt^oiLH fltTbi'tion iK:ciini in ixmrtxiun wiih thi? noio, Purident diBctiai^ taa 
tak^Ji [ilacB fur nidk.- lIuil- iVoiii ttie iiii^iUlli fiiiddeiilj- IL ceoHvn^ lU-aili tn^uuSj with Inn*! 
symptoms; and nil diuwtina, corieB of the mlirif^Tmi jilole of the tllimmd boni^ iflfound. 
*Tilh corr^poiiiUnff aflectloii uf tht l^n. 






SOS ABSCESS OF THB MASTOID CELLS. 



Ahsci^u of the Mastoid Cells. 

Tbe inAa.mmator/ process may originate in tLe cancell&ted lextnro 
of tliat pari of tlie tenipoval bone which conetitutes ite mastoid pruceM. 
It may be tbe result «f exleriiiil injury; more frequently it occurs 
■ftithwut any appreciable exciting cnuse, in systems of the sirumooa 
character ; and is most especially liable to invaite those, whose ori^ual 
cachexy of Byslem h&3 been aggravated by JmiiradenC eihibition of 
mr^rciiri:Lk. Like the preceding affection, it is most freqnent in the 
young. But very often this disease is but the extension of an originally 
mere outward affuctioD ; namely, long continued inflanimatioTi of the 
esleroal meatus- If suppuration be attained to — as ia extremely pro- 
bable — curies may hardly fail to be established; and is usually com- 
plicated wiih necrosis, portions of tbe osseous teititre separating ia the 
form of aequeatra. From the near connexion of the posterior aurface 
of the cells with the dura maler of the cerebellar cavity, it can easily 
be understood liow readily, in advanced cases, the latter textnre may 
be involved. The lateral sinus, too, ia in close contact; and perfo- 
ration of tins vessel gives rise to two formidalile dangers, liemorrbage 

uid pyj^mia^ 

Supposing the affection to be primftry^ treatmeiit in the first 
instance will bo directed to averting auppuratiou and caries, if possible, 
by the ordinary means. When there is reason to believe that matter 
htA farmed, we shaJl lie very anxious to obtain an early and sufficient 
opening eaternally, and thus to limit llie mischief already Jone. 
Otherwise, there is great danger by extension. The internal ear 
tuving been involved, hnpdess denfoess will enBiie ; pnralvHifl of that 

side of the face is not luilikely* trora implication of thi; portio dura; 
nay, it is possible that the contenta of the cah'arium mny be attacked, 
ae already staled, directly and imniiticntly perilling e:iistence. But, 
indepndently of such aggravations, life may be hazarded by the hectic 
of A continiLcil and waiting discharge. 

From locnl trealmeiit alfine, but little gf>od need be expected; 
constitutional means must bo at tbe Hame time, and sedulously, 
employed. When employing counter -irritatioa, the blister should not 
be placed over the part affected — otherwise the disease might be ia- 
creased — but at a distance, as on tbe nucha, or betweeu the shouldets. 

This ct^nstitutes inie earacbe; a neuralgic affecl ion, unconnected, 
directly, with the inflMmmatory procesa. Very frequently it is con- 
nected with irrilatioTi in tbe mouth. The pain is very distressing, and 
haa all the ebiiracltrs of neuralgia. It is amenable to ibe same trent- 
ment, neareh for o. dental caime or cimneiiou never being neglected. 
Among the anodrnea suitaide for application to tbe part, acouite and 
belladonna deserve a prominent place. 



DEAFNESS, 



209 



Denfnfaa. 

Deofheaa ibs/ proctied from the aSl'Ctious uln^ady mentioned, and 
from many catiBCs bcsido. In order Lo urri^^o at a true dio^osia, 
carefnl ^xarnt nation of tbe exlemal manias, and (if tlie m^mltratia 
tympani, is essential ; aLd to effect this, the well ]u;ide speculiLin is of 
great eervice. 

Deafness is very freqnenlly occasioned by AccunatlatioJi qfin&pissated 
Cerumen wiihin the nieatuH- Or, perliapH, obfclniciioa lo the vibmtions 
of sound IB rendered atill more eifeciual, by commixture of wool or 
cotton •w\i\i the cerumen ; thp patient having Wn in the liabit of 
negligently stopping his ears, besides forgetliag lo practice requisite 
cleanliness. Tbe presence of obstruction will be at once declared by use 
of tbe 6|iecnlum ; and often that is not necessary ; tension and straight- 
ening of tho tube, by pulling tbe lolw, before a clear light, being sufB- 
cient. Remedy cimsisti^ in removing tbe oi^endiug ma^s. And this Is 
best effected by washing out the meatus with hot water, by means of a 
Btout pyrin^e. Instruments such as employed for gonorrhoea, or for 
the injection of sinuses, are wholly inefficient ; the syringe should l>e t»f 
melal, well valved, and of considerable power. And the injection is 
jiernevtred iu, tilber at one or at repeated eittiJigH, utLllI the inembrana 
tympfini ia disclosed cUar, on the nse of the Bpeculum. When the 
oeruuien i» annsually hard and tenficious, it may be luoHCoed^ previonaly 
lo syringing, by the careful use of a curette, or by moistening it witli 
bland oil for a day or two, 

Dejiciencif of ceruminous Mecrelion is an occasional, bul much leas 
frequent caaae of deafne^. The meatus ia found dry and empty, and 
tho membr^ina tympani is eecn clear and glistening. StimulantE aro 
of use in rest{>ring the secretion — as the essential oils, more or less 
diluted ■ and their action may be further assisted by utlmulant friction 
around the auricle. Exhaustion uf the cavity is said also to have a 
beneficial effect ; hy means of a syringe, fitted with a soft nozzle which 
completely occludes the meotuft. Until the lioniiiil eecretioii returns, 
glycerine applied by meana of a hair pencil will bo found a valuable 
Bubetitttte,* 

Thickening of the lining membrane of the meatus ia a cause nf deaf- 
ness ; tbe result of chronic inflammiitory disease. It ia to be treated 
by the application of gentle stimuli — such as solutions of nitrate of silver, 
sulphate of zinc, &c.^'wbieh are beat admiuistBred by meana of a hair 

Ipfneil. Be^^ti^catJon of the general health, and counter- irritation behind 
the ear, are often useful auiiliaries. 
The membrana ft/mpani may be changed in structure ; thickened and 
congTHted; the result of inflammatory disease. Similar treatment is 
advisable ; the stimulanui being apphed by means of injection ; except 
when the membrane ia imperfect, and then again ibe hair pencil 
• Waki.KV, Uncoi, No. 1340, p. 031. 




DEAFNESS, 

becoTQea preferable, lest undue excitanient be catiBcd in the intoruftl 
etw. Iraperf<?cLioa of tlie membrane, by iJcerfltion, or by nipLure in 
QonBeqiietice of external irjniy^ laay be rejinired by Nature's effort. 
If not, ht'itring may be much {luiokened by applyuig a Email shred of 
Hflt, or cotton wtwl moiatened in glycerine^ over \he a|iertnre.* Or an 
BrtiSci&l n]<?mbraDft may bu adjnatcd and worn, as recommended by 
Mr, Toyobee. 

By hyperirophi/ of bonHy the oaseoua meatus may be so contracted 
and cbaD*;c-d, as to prodnco a considerabltT omoimt of deafnefis; an 
affection obviouKly btil littk amenablo to tn^atment, 

The internal ear may be dieordered; and on this cause the great 
majority of cases Lif deafiieea are found to depend, f The change may 
be in the lining membriLne, in the o^kpohr testnre, or in the nerves. 
Fortunately, modern resejirch has declared the most usual aito of dis- 
order to be the testnre fiT>^t named — tlie one most amenable to BncceBsfal 
treatment. Tbia maijdv connists in attention to the general health, and 
patient perseverance in the use of conn ler-irri tat ion — the latter preceded 

by moderate local dejiletioii. 

The extremitif of the Euslarhiiin tube may Ihj obstrncted, in varimia 
w^yHy and deaJneBB ensue. It may be shut up aud compressed by 
enlarged tonsils, or hy naKJii polypus banging low from the posterior 
nares, In snch casefl, deatnesa will disappear on removal of the tonsil 
or polypnp. 

Congestive swelling and relaxation of the fauces may catase obslniC' 
tion of the tubp ; to be removed by astringent opplicsitions, counter- 
irritation, and Mitention to the general healtb.J 

Ulceration of the fancea, iniplicating the extremity of the EuBla- 
cian lube, may cause more serious nbfitniction by tlie contraction which 
occntB on cieatriEation, Thia is to he obviated by speedily healing the 
nicer, while yet enperiicial and of slight exteol ; Euid i& to be rGiaedicd 
— if possible — hy thp introduction r>f probes, or eatgnl bougies, whereby 
to effect gradual dilatation of the eand. The probe, or bougie, about 
six inches long, and suCieicnlly curved, is introduced along Lbe door of 
tbe nostril, with the convexity upwards ; and, just before tbe phaiyni 
is reac^licjl, it is gently turned so as to bring the point outwai^la and a 
little nprt'arda — the mouth of the Eustachian tube being abovt? the 
level of tbe floftr of the noslnl^i. If the tube is opeti, the instrument 
will be plainly feit entering it. When obntructioo or obliteration 

• LA?fCET, Vd. I39fl,p. 10; urf Ko. 1298, p-W," 
t ToiflUfcii. Med. Cbir. TroMacL voL xoIt. 
X C|riime_*tfi i>f t}]ft tiibe ih Adrertainel by dirot'ting the [iDrii:4it tu «lmt hU ra^ath uiiT 
QWtril^, nnj then tu expire furcihly, a* if Wowing lis ama. Tie will bo Btinaibln of » 
"^Ikk in iht ear, priducerf by the shDck of air a<.'tiiiff □□ Ihp membnuiJi tympinl— *np- 
poiinpr tb« lu b*- i^nlire; unci ibc sound will be wry plAJnly h^jotd hy tho purgeob, 
tbtou^h a itutboaocpt; placed on dtc mutoid proctwi. If the Ubt ht open, but vlfljrgnL 
wilh RiucoB, the noiiw Is ofa gurgling or craekling kind- 



rSItFOBATlON OF TEE HEUBEiANA TYMrANK 



211 



exists, pre«wnre jg to be made where the normal ft[>ertnre ought t/i hv ; 
in th? \i\ypG tbat tbns tbe obstnictioQ taay be ovi^reomc. Sometimes 
the operatian ia at least, partially succeGsful- But in too numy cases, 
this as well aa the other operations on the Enstachiaii tube, are 
found to be not only difflciilt in perfortnance, but also nugaioij in 
their result* 

By cftthetcnsni, b8 it is termed^ it is prnposed to rid the tube of a 
redundancy of mucus: — another cause of deafness; but that will pro- 
bably be as easily and certainly more safely accomplished, in most 
cases, by general treatment, gargles, and count«r>irntation. In chronic 
aflfections of the membrane of the mid<1le car, it is possible thai benefit 

may aoincHines follow the careful injection of water, air, or tnedicatctl 
va|>ourT into (hat ciivity ; and this is accomplished by niejins of ibe 
tnetallic Eiisiachian catheler — introduced in the same way us the 
probe, ajtd fitted with a snilahle ayrin^. All such operations, how- 
ever, mtist be conducted with the greatest caution ; seeini; that it 
requires but liltle morbid thauge in tbo bony walls of ibo lyiupanuoi 
to produce an almost diroct comMunicutton hutween that cavity and 
the interior of the eraninm.* 

Organic change in (he brainy or in the auditory nerve, is ni>t an 
un&eqnent cause of deafuefis ; and seldom admiU of sueccsaful treat- 
ment, Hopes of aniendmt^nt will mainly rest on coimter-iiritatioti, 
and on mercuriahsm moderately employed. 

PuTtctional disorder of the nerve is fortunately a more frequent* jm 
well aA more hopeful eauflo ; varionsly induced — as hy blows, falls, 
loud noises, disorder of the general health, itc. Besides obnntin'^ iLe 
inducing cauwe, employing counter- Irritation, and perhaps venturing 
on mercurialifim, benefit may he obtained from the endermic use of 
Blryclmioe — an in the analogous ca,se of fanctional aujaun>siii. Or a 
few drops of an alcoholic Eoluttort of strychnine may be dropped inLo 
the ear, from time to time. 

Detemiinatiun of bhiod to the hcad^ in consequence of suppresaiini 
of normal or habitnal discharge, or however induced, is not luilihely 
to produce a certain degree oE deafness, along with noises and other 
impleasaut eeuaations (u tht: head. Treatment i? by leeching C}X 
cupping, purgiug, and other means ordinarily found available to 
overcome local plethora, 

Perjbrntton of the Mfmhrrma Trfrnpatii. 

This little operation is not frequently reqnired- It is deemed 
ailvisablc when, by insuperable nhatniction of the Enetachian lube, 
aceesH of aimospheric air is denied to the cavity of the tympanum; 
and olsc when that cavity has become olistructed by extravasation of 



* TovNBBE, Uodico Cbir. TianBicL, vol. xxxlv, 18^1, 



212 



HEHORUBACE FROM THE EAR. 



liliKjJ. ThG eipediency of simplp pimctnre, iD the case of absceBfl of 
tbe tympanum, Iulb been already noticed- 

In cases of deafneBs, caused by obstruction of the EnstacLian tube, 
it is oiir object not merely to make an a|)erfiire in the membmne, but 
to keep tliat ptrrvious ; and bo permanently li> alone for want of the 
nociii^tomvd Atmouphenc eiipply in tho middle ear. Thin may he 
jicoomjiliHlieti by using the instnimenl of Fabrifici. *^ It conswts of a 
canulaj inti> which Kbdes a spind ivire, someivhat resembling tliat of a 
cork-screw. It is to be uped in the fi^llowitig manner : — Pa^a the 
carnU with Ihfl spiral wire down ujon the inferior pari of the inem- 
brana tympani (so as not to interfere wilh the manubrium of tbe mol- 
leiie), retain it ihere vith th? left hand^ being cart^ful not to prtres too 
firmly on the membrane ; then, with the right hand, take hold of the 
STuall handle which rev<ilrefl the Hpirid wirej and lum it from right to 
left, boin^ what is usually called tuniing (he u^ong v:aff. The insLant 
at which the membrane is perforated is sensibly f«lt by the operator. 
The wire \h now no hm^er ti* l>e tunied \ but by ila handle the instni- 
ment is to be retained in ila situation ; then gently rev<ilve the Cfmula, 
which has a cutting fdge» from left to right, i\'bea a circnW portion 
of the membrana lympani, corre&pondiug (o the diameter of the cauula, 
will be cut otitf nn^I nL the sa^n^ time drawn inUi llie canula and held 
fast by the spiral wire."* Or, instead of this iiiBlrunientj a trocar, 
volule and ahnrp in the sidts, muy be employed ; tarniug jt quickly 
in the membrane, so as to excisa the punctured portioii. 

I/anorrfujge Jrom flte Eor. 

Blood, escaping by the ear, may proceed from various sourcefi, 
and requires diflerenl Ircalment accordingly. I. One of the most 
promiitent Bymptome of fracture at the buae of the cratiium ia bleediitg 
from ihe ear; amenable to no direct treatment; and usually an un- 
favourable omeD- 2- Mere laceration of the lining membrane of the 
meatufl may furnish a copioua discharge of blood ; indejitndent of any 
injury done lo the cranium, or elsewhere. It, too, requires no direct 
treatment — not t>eiag likidy to ^rove escesttive. And it is nut a sign 
pf an unioward cliftractLT, It may he the result of ft blow, fall, or 
direct injury done lo the part. 3. Passive hfuuorrLage may take place 
from this, as from mucous surf&ces; amenable to the ordinary treat- 
ment, loe&l and constitutional, suitable in such cases- 4. The internal 
carotid may Lave been opened into by ulceration. The hemorrhage 
ia constant, topi^m^J and of the arterial character- Pretfiiiie may he 
tried, with styplics, but may fail. The only sure r^merly is ligature of 
the common carotid artery, 5. The lateral sitms, opeind by ulcera- 
tion, may Iw the aourca of bleeding — dart and venous. In this case, 



* Williams on the Ear. p. INH. 




CTONGBNITAL OCCLUSION OF THE MEATUS. 



213 



while lI^^utTirti of the cttrotld wuulJ prove wliollv iiugalorj, Dioderatti 
pressure is found to bo quito cfTecLuul- 



H^pci-troph^ of the Auricle. 

Hypertrophy of the whole auricle ia an occaskmal, though rare, 
occurrence. Parlial bjpeilropby — affecting the lobe only — is more 
freqncDtlj met wich ; uod chiefly in women. If cxceBsi^c And irksome 
to the patient from its tinscemlinefia, the redundancy may l>e removed 
by the tnife. 

This deformity, however, may be attifieially and intentionally pro- 
duced ; as by those native Indians who wear a dagger sU5|>ended from 
the lobe of the ear. 

Otoplmtia. 

Deficieocies of the anricle — by wound, ulceration, or sloughing — 
may be repaired by autoplasty. Restoration of the entire organ ia 
scarcely to be attempted; but a portion may be readily replaced — 
when luily of the surrounding intcgumeni ib favourable — by an 
operation condiioted ou tbe same principle aa rhinoplaflty. 

ConffKmtai Occlusion of the Meatus. 

The Tueatna may be con^mtally imperforate. It may be Fully 
developed in all respect,^ but covered by integinnenl. In such a case, 
eimple incision of the ekin, and cureful dre^iQg of the n^onnd, so els to 
prevent ointraction, will aiiffiet ht pstuhli-^h the normal state. 

Or a thick flewhy covering may euiiceal the cartilaginous tube, 
which ia only pnrtiaily developed. And in this case a more careful 
and regular dissection may obtain a eimilar result, but porhnpa more 
imperfectly. 

Or the CKternal apparatuE of hearing may be altogether deficient ; 
the bone itself being imperforate, fineh oases are wholly beyond the 
reach of our art : yet it does not follow that hearing is dcnie<ij or even 
very imperfect. A boj^ a^d fonrloeii, came from a dii^tance, desiroua 
of having an aperture made in each aunele ; and each of these organs 
wiLB found very impiiriecLly developed, of a shrivelled appearance, and 
wholly imperforate. On making a very careful diBaection down to the 
bone, in ueareh of an external nif^atns, it lieeame apparent not only 
that no siich lube exiKteil, however imperfect, but ihat also there 
was no a[ierture in the temporal bone. Yet the patient heard ordinary 
conversatiun, if distinct and rather lovid ; be had gone to school at the 
Bamc age as other hoyn, ai^d had made equal proficiency in the ordinary 
branchus of education, althongh do unusual means of teaching bad 
ever been applied to him ; and he ssflifted hifl falher in the tJccu[>ation 
of a butcher, with much smartncBs and intelligence, A series of 





CONGENITAL OCCLDSJOS OF THE iHEATtTfi. 



experimeDts, cooducled by my colleagues, Profeesora Forbes and 
ThoniBOTi, seemed to sbow that be heard mainly by coDdoclion of 
soanU ilimugh the bones of the cranium to internal ears very perfectly 
eoDslnit^ttJ.* 

lUrd, Traill d« Mdadit* de rOrtfUle, Pari*. 1821, Abercioinbie on DieeiBW of Ibe 
Bniri, At, EdiD. IB28. Bright, Huapiul Efp-irta, toI. ii. pari i. I-(Mnlon, 1631. Krtnier, 
(mDiseiuet of tho t^r, Berlin. lH3ii, trAn^lulvU liy B«niii'll^ f tidier, itn E-lie 9lructiiT« 
lUid Di9eiiiM4 or Ihe Kur, Lundon, ]8,'t8. Williums, ob iLlh Fjit, IjuiLlnn. 1K40 Wildo 
na Otorrha'a. Dublin Journal of Ifvd. Sck'uop, ilaii. 1^4-1. '\\'ar<teii, Lldit. T^. JouT 
Lkl. 1««- Ycorfley, Lduct^l, IfWK, vi. ii, pp, ]l»»W, a;c And Mr. Toynbw'n varioiu 
pJipRH — iMpilini-Chir- Trail lactioiw, vciU. "siv. iin<l xnxiv-— BT'-d. Gairt^llv, JiiK- lftJ3— 

Uvutbly Jounul, F«U ltM9. 



HoiiLbly JfrtintAl, Dfr- lMG,pp.430ai]d 739- 



S15 



CHAPTER XVIIL 



AFFECTIONS OF THE NECK. 



Oinndui/ir Enlat'gi'ni^nt and Abtcfjts. 



Is »icrofulriU9 odoleiicoiitB, the gUnds of the Dcck »re very liAble to 
enlargement, by i\ chmnic inflamniatory pri.)oeaa; Jind frequently, 
notwillisUu'ling e'vevy elTort lo the contrary, siippUTation is readied to 
— cuusing more or less defurraity "by unseemly cicalniaLioii. In ibe 
iituwont eUpe, WH endeavour to nrrcst progress ; by otinHlitutional 
treatment suited to the stnmoiia JiatbesiB; by leeching and fomen- 
tation; and bubfieqnL-ntly, by the application uf iodine, or other dis- 
cutients, or hy Rli^^ht [."onnter-imlaUo]!. When niiitlt-r has furmed, 
an early evacua^on is prflctint'd by iiici^iiou ; ilie woniid being made 
03 minute as poaaiUlc, and in the direction of the folda of tlie neck, bo 
that i\£ cicatrix niiiy efjca-iia observation, A coniniou laneet ib the 
preferable instmmeiit. Soin*.'tiiues, however, the nse uf potana is 
demanded ; the interments having been mucli Aindermined, and the 
gland rt-qnirinn; disinlegrationp 

Iti Ihe after-treatment of suppurations in the neck, cure is often 
dtilajcd by over-drefisin^ tbe jjArt — covering: il wilh loo many envebipea 
— H»sp*?<:iiilJy xvlipii tht* patioiit is not eonfin<id to llio lion^^e. Thr object 
of such dressing- is to conceal ilie wtate of inalU'i-s from pnblie obser- 
vation, and to guanl against espoaiire to cold ; ifut Ihe result ofien is, 
ti) maintain a degnitf of cofig*^Bli<in in the part, favourahle to cDiiLiniied 
aiippn ration, and unaiiited tu eonuactionaud consolidation of the ahHceas, 

Wlicn abscf-'as iiaa formed at all deeply in the neck, whether c?on- 
ceeted or not with glan<liiljir enlargement, ei'af?naLi)iii by incision eannot 

be too Boon Lad rci^ourse to, otherwise serious miseliief can scarcely 
fail to en,sne- Faacia is mrido to slough ; areolar tissue is hroken 
down; the trachea and osophagna are each liable to be opeiie<l into 
hy ulceration; the ju^idar vein may cominnniciile with the abf^eewa; 
or, still more disastronsly, by eominuniealion with the carotid artery 
thfl ry&l of the ahscess may be converted inbi the sac i>f si false ane« 
riam* And then, when the wonnd for evacuation — too lonj; d(!layed 
— ia at length made, the most serious conseqiiencefl are inevjlable,* 

* Monthly Jduraal, June 1B55, p. 352. 





21fi 



TUMOURS OF THE NECK_ 



Hcmatoctle of the Neck. 

Hematocele of the neck ia not uncomiaoii ; origiaaliDg in lesion of 
a superficial vein^ and Ilie contents of the cyst being more or lees Ban- 
piinolent. The cyst ia thin^ anperficial, and scUom of very large size. 
Uauallv tlie proHnetion nf tbr KWelling ir snrlden ; and ifa progress m 
growth may be rapid ; after a time, however, becoming stalionaiy, and 
proving incnnveniect mainly by ita bulk. Tapping, with subsequent 
injection of iodine, may be tried ; as in serons accumulilione. Sbuuld 
tbig fail, a small Geioii may he inserted ; or free indsion may be 
practised, with subsequent granulation from the bottom of the wound- 
In the necks of young cbililrpit similar swellings are not nnfre- 
quently obaerved, altogether imconnected with blond or blood-vessels ; 
the contents clear and albuminoiLs. 



Thtmours of the Neclc. 

Solid tumoTii-ST when of such a nature as not to he amenable to 
diBCUGSion, cidl loudly for an early use of the knife, otherwise eacli 




Fi^, SB. 



day will but add to the difficulty and danger of the operation ; »nd 
when at last malt^^rs are found U) brook no further delav^ it is not 



Kig, 8'L Ijirgf tibroup* liimour growing from the neck. Wm ancteirfiilly remowd. 



OrHNlNG OF THE KXTEBNAL JUGOLAB VEIN- 



217 



mpoR^ible but tlie hazard may be Jbund 80 miicli increased eis to render 
nny rtltempl al extirpation qiiiie unwarraiitaLle. 

In connexion with this fiiihjecl, it is well to remember, that in 
consequence of a tumour Wmg bound firmly down by the deep and 
strung (rervicid fast;!^, Il may seem to be less deeply seated tliui it in; 
and that, consequently, much caution ie alwaja expedient in conJuot- 
ing the dissection^ it being not at all improbable that the common 
Hlieath of the lar^ vessels may be fully expowd — perhaps to aome 
ej:teDt. 

Opetting of ikt External Juguhar Vein, 

Occasionally it iti dcemt^d cxpediont to abstract blood by opening 

this vein, at iLa lower part. By presanre of tlie thumb, d^pplicd im- 
mediately ubovo the cla- 
vicle^ prominent billing of 
tbe vein is produced ; and 
thcu an iucttiiujj Is inader ati 
in venesection at the bend 
of the arm. The thumb'g 
presaure is maintained, so 
long as the flow of blood ia 
desired ; it \s then with- 
drawn \ ajid this circ;uiij' 
atan<%, of itRclf, ia uanally 
aufficient to arrefit the 
bleeding. But, be&ides, it 
LB well to p]ace a Email com^ 
preea on Lhe wound ; re- 
tainifig it by nieana of a long strip of adbeaSve plaster, or by a bandage 
very lightly applied. During the blood's flow, precaution iB advifiablfi 
to avoid entrance of air into the vein. 




He «^ 



TortitiollU. 

By thifi term is understood a diatortiou of the neck, dependent on 

njUBcular Jifiorder — apoam, ^mralysis, or cJiango of Htniclure- Tbe 
muscle usually to blarae is the a terno-clei do- mastoid. One, acting 
with lhe undue energy of spasm, overpowers its fellow, and displaces 
the neck accordirjgly ; or one, affected with a loss of contractility, 
feile to affiird the usual counteracting power to its fellow; or, by the 
inHamuiutory process and lis rei^ultu, a.bbrevJuEioji ajjd uoudeiLSaLton of 
one or other raiaacio may occur, cnuaing difitortion of a very unpro- 
mising character; or the malformation Is con^enitab 

Children, shortly after birth, are not unfrequently found to labour 

n^. 83. VaDHectidii in \h.t a«k. Tlif luctflmhl jiigultr ^r>wa dutvniled hy preMiin 
nf the thumb, preThiusLy tu biBerticin 4>f lhe Upcet. 



ilS 7vjn[corx[& 



mcenun usooot of torticollis, fnmi the aet^onr) ean?^; t^ne of 
te nosck* seeroin^ either to have been inadequatelf developed, or 
■PmAow to hive be«>nte partiallf (Anlyced. Friction over the Kpine, 
■■d oo the mosek vhkh u weak — with care, on the part of the nune, 
to ^x^Tvise the bult^ muede hv poailiou of the head, jel niULOUt 
h^^mg the exteiuora — onmllj- «iffie«s to effect gradual hnt satia- 
ftotoy amBDdnmL 

Id a anBar state of matterfi, in the adolescent or a^ult, the 
cndermic mat of sirTchQine, or tlie electro-m Acetic stimolus, may be 
bad recoonelD. 

SfNHiQ pf the masde maj be either femporary or pennanent. 
Thv Ibrmer movt frvquetitTr oectire in children ; and is to be ttvti.ic3 
br ]wirgatirefi and alteratiTps, followed by anli-ripasmiidics infernally ; 
IocaUt by fomentKtian, leeching, and counter imUtion. PermaDent 
spaAiG rigidity of the anaele is more cotmoon in ila.^ adolesccul and 
adult ; periu^n a remote coosequence of the f<inner affection. Mercu- 
rial tiKtioii aod active coonier^imtatiuD may be tried; bnt with no 
mttguiDe bo^i^ of Foecesc. Sooner or hitcr, (eootomy haa to be eca^ 
|Joy«d ; and thai nat merely on aoconni of the deformity, but to 
avoid a toore s^rions evil — cutvalure of the epine — which often saper- 
voiles,, and which may, if onchected^ become both extensive and 
eonfinued. The neiHlEe is ias*^rted obliqoely, at the origin of the 
muscle fn>ni the stenmm and clavicle; and division is effecled by 
catt^iu^ either from wiihoitt mwMxU, or in ihe oppo^le dir^tiou, ub 
ciTCUmslances may se^tn to regain*; great care being of conree taken 
not to injure the imjkortant parts which lie immediately behind that 
|k*rt of the mu^lc- To infiire safely in this respect, it may be well, 
III some casps to [ninolure with the onliaary teiioiumy 'needle or knife; 
and then, withdmwin^ this to enlviitiite nn i[i^:ti]i]]eDt with a probe- 
point whcrrwith to cffoot the mn^le's Gection, Sometimes it may be 
sitfficirnl to cnt only one origin : biiL usually, division of both heads 
is rf^'ntial, By rv^Iiencc of the severed extremities, restoration of 
the nonual i^talc is at once prodiKwtJ ; and this h muinlaijted by ali^ 
able l^nda^ni;, if need be. nntil conK>lidatiaD of the divided parts 
oocar, with the due amomii of elongation, 

A siiwilar o^xTAtioii is ilic only mcan^ whcreUy we may expect to 
coh* thtf third fomi of the aflwtion : that proceeding fmp] fltructural 
chan^r by inltammatiim and its rt^ulls. 

Twisiiiii: vf lite niH'k is causcil also by tomoUTS — glandular and 
others: a» vtel! i\s by the eon1ractt<>n of eiteusive burns. The prin- 
t:i[ihu of tiratiueiiL in these cases are obriotis. 

Wmntts (/fJbr TkroaL 

W oiniiitf of the throat are of two claaseA; those inflicted by the 
hai>d of the suioidc, or the murderer; and those made by the fiur^^eon. 




WOLTiDa OF TDK TBKOAT. 219 

The futroer notv engage our atteixtioo. They are usually made in a 
transvorae tlirocdon ; end high in the neck — ^rear or at the thyroid 
cartiliige ; the liitter circumstance Win^ iiroLably connected with the 
popular idea, that, lo effect exliDctinn of life, it is siifficieiil to open 
the aLr-past^age, and so cause Bu6c>cution. The extent and cociEeqntDt 
im|>orLance of such injuriea vary very nrncb ; from mere scratches, 
penetrating: no deepr than tht subtniaueijna areoUr liasoet to tlie 
most ghastly severing of all textures — almost to decapitation. Some- 
times tbe incision is ma^le immediately beneath the chin. Not unfi^^ 
quently it is placed between the byoid hone and thTroi'i cartilage ; 
the mouth being opened int/i^ and the air-passage left mtJict, Some- 
times the wtjuinin is drawn across, a little above the clavicle ; and 
then, if any considerable depth be (tttaincd to, death is certaiu and 
immediate, ^metimes the knire^ held im a daggf^r, is pluitgeU into 
the lower part of the neck ; to the imminent risk of the larger blood- 
vesselfl. Hut the region of tie livrj'ii:i ia that which is most frequently 
involved. 

The first danger is by hemorrhage. If the carotid nod jugular 
Lava been reached, death is very speedy, and may scarcely bo pre- 
vented. Snch extreme wonnda, however, are of eoniparalively rare 
occurrence; the vcBsela being protected, high in their course, by the 
depth of their situation in reference to the front of the neck, and by 
the density of the p^rts which have to be divided ere ttie sweep of the 
fiharp edge can reach tlieni. When, however, ihe deed is nltempted 
with a truer pkill and deliberation, not by a borizoEtal gash, bot bj a 
puncture in the direction of the veestda, the escape of these ia likely to 
prove rather the exception than the nile. A more limited transverse 
wouofl, leaving the carotid and jugtilar intact, may still cause death 
by hemorrhage, directly, nnd within a brief period; by implication of 
the thyroid vessels — arteries and veins. And again a comparatively 
slight bleeding may prove fntftl, mure remotely^ blood trickling into 
»he larynx, and acenmnlnting within the nir^passage, so as to induce 
aaphyxia; euch accumulation bt'ing permitted by the inBensibility »if 
the patient, or by his inability, through faintness, t« make the requisite 
efforts for expectoration. 

The eecoud danger is by inflammatory changes at the wounded 
part; occlodiiig the laryngeal ai-erture or canul, or otherwise inter- 
faring with respiration- And this is all ihe more likely to occur, if 
the wound have been brought together tightly, with au imprudem 
haste. The mucous mcuibrane, as well aa the rest of the wound, 
becomea the seat of an acute infli^mniatury process ; and llie conse- 
quent swelling may lie such aa to cau-se rapid and great occlusion. 
At the same time, mueoua secretion ia both mereased in qiifintity and 
vitiated in unality— becoming more viKcid and tenacious. This, accu- 
mulating in the idreaily narrowed canal, renders suffocative hazard 
-lore imminent. And the risk is fnrlhet contributed to, by the 



J 



220 WOUNDS UF THE TSHOAT. 

Jiiainishcd ^wer of expectoration ^hich B pationt bo situated necen- 

A third dim^r^ liable to occur aJoti^ with, and to ag^avatt? tbut 
which iifts jnstlietn considered, is — that, cliiring tlie movemetils of lie 
part — voluntary and iiivolimlary — one portion of tbe woiUid is not 
unlikely to ovfrLijj the other, aud thus, by saddealy jirodinjingr a 
nieohnnical obfitniotion to the paeflage of a\t, tit once to bring life into 
the greatest peril. 

A fourtli danger is by tlie occnrrence of inflammatory cbange in the 
trachea and liinf^ ; the inflaraniatory process extending do^^nwards 
from the wound, or the unwonted direct access of coM air proving an 
exciting canse of original affection. Bronchitis, indeed, more or less 
severe, is almost an inviiriahle eonacqucncc of Hich injuries. 

A fiflh danger arises from inn-nition, in those cases in whict the 
g^nllet has Buffered ; and when, consequently, it is not easy to main- 
tain a dnc supply of nourishment. Hcclic, aim, may ensue, in the 
case of an cstensive, profusely suppurating, and slowly healing wound; 
more e>^i>ecially if much blood have been lost ut the time of the inflic- 
tion of th"? injury. 

And lastJy, the mentfll condition is, iii till cufps, liliely to exert in 
untoward iufinencc on the bodily frame. Tn not a few examples, 
when dissipation has led lo the rash and guilty act^ life is perilled at 
an early period hy the occurrence of delirium tremens. Or this, 
indeed, may have been some time in progress, fl.nd may have ctmsed 
the suicidal attempt. And in ihoay caaee which have been preceded 
by gloomj', hrLioding despondency, a ci'>n tin nance of low mnnia, accom- 
panied with ty|ihoid symptoms, will usually paralyze our best remedial 
efforts, and determine a fatal issue by linking. 

Thus it can be readily understood^ how few caKts id Surgery pre- 
sent more obstacles to salisfactery treatment than do those of cut throat. 
We overpftHS one difficulty and danger ooly to meet another. And 
too frcipiently, after the moKt pr-.uiinenfc evHs hiive been skilfully 
counteracted, the patient slowly yet surely sinks under obscure typhoid 
symptoms, intimately connected ^vith mental alienation. 

Treatment. — When called to a case of cut throat, it is obviously oar 
first duty to arrest ihe beoiorrhage. And this is done by Ugature of 
the arterial orifices; pressure being npplicd, if need be, to venoaa 
pointfl. Then the wound is tn he ajiproiimated by snture ; not wholly, 
bnt in part. The anRles are drawn and kept together; but the centre 
of the wound is left free, approximation there being effected solely by 
attention to position of the head — keeping the chin, by banda^ng if 
nece^ary, depressed towards the sternum ; and even this is not done, 
until all bleeding from the wouiid has ceased. If the chaam be at 
once drawn tightly together, immediate risk is greatly enhanced, as 
already slated ; and yet ibis is an error very Frequently committed, in 
the hnrry of actual jiractice. Blood, oozing from the cut parts, dooB 



M 



WOUNDS or THK THROAT. 221 

iwl find a ready escape externally, but eitber trickles into the air- 
pasBage and acciimulatea slealtbily there; or is infiltraled around the 
line of wound, cansing compression af the windpipe by tbe increasing 
GoagijluoL ; in either nay tbreJiteoirig^ sufTDcatioEi. Thu vii^cid luueufi, 
too, IB more ILlcdy tu entangle itiielf in tbe ahni wound ; oiid iuHam- 
matory tiiTgeflcence is more prone to prove untoward. Air, also, ih 
likely to be infiltrated into tbe areolar tissue, during; expiration ; causing 
tronblesDme and dangerous empLystmn. When, on tbe contrary, the 
wound is left centrally free* these latter rifiks are not only less likely 
to occur ; but alho, in the event of their occurrence, untoward tendency 
can be mucib mi:>ro readily and efl'eclu Lilly emmtcracted. It need 
scarcely be added that tbe drehsing of the wound should lie moKt 
ainiple; consisting, not of a complication of plaster, compress, and 
bandaging — but of a mere strip of Lifjt, moistened in water, and loosely 
and lightly retained U(wn Ibe part. 

Tbe main bleeding having' been secured, and tbe wound partially 
approximated, tho paLtent ie laid on his aide &.> as to favour outward 
escape cf the continuei] oozing. And the cut part is protected from 
nnfftvoiu^ble atmuspiieric impreasion, by a coTering of loose gauze, or 
of woollen texture, thrown lightly over tbe neck ; attention being at 
tbe same time paid 1o maintain an i^qnable and genial tcmperatnre in 
tbe a|iiirtineut. Didy qualified atleudanl;* are at baud no! ouly to 
guard a^auj&t rcpfiliEiou of Uio euicidal attempt, but aleo prepared to 
Feparale ami ele/tr the wound, should swelling anH eiilaiigb'in^'nt of 
mucus render such a proceeding necessary to prevent suflbcatiun. 
And the patient should be instructed to facilitate his opec to ration, 
by completely shutring or Tery oiucb diminishing the wound, by 
means of his flnj^erf*, at the time of iJie effort being made. It is IJO]Xid 
that ih^j wound will indamL', gionulatOr contract, ;uid cicatrii^e, in iha 
nrdinary way; and the local treatment is conducted with that ohjeet 
in view. Constitution ally, we have to guard against favouring inflam- 
mation in the wound, and in the air-passages, by neglect of anlijjh- 
logistic measurf s ; and, on the oilier hand, we must beware of aggra- 
vating (he tendency to sinking wliicb sooner or later becomes apparent 
ID tbe- majority of coseB. As a genorul rule, blood-letting frooi the 
BVfitem is wildom if ever wnrrftutablf. 

Sboiilil the pbar3-nx or cetopbagua have been wounded, the uae of 
a tube becomes necessary to convey nonriabment to the stomach. In 
the ordinary effort of deglutition, the ingesta would necessarily eacfli>e 
more or less copiously by tbe wound, and so do barm in many waye. 
The feeding tube cannot be inserted from tho wo^md^al though tho 
facility of suclk a proceeding may inviEo Ibe attempt — otherwiso 
closure of the wound must be Beriout^ly inleifered wiib. If intended 
to be introduced and worn permanently, until the pharyngeal or tcso- 
phagenl ai>erture shall have closed, It is to be passed by the nostril. 
I3ut it h found to be more expedient to introduce tbe Lube only ix;i;a- 



J 



222 



WOUSDB OP THB THBOAT. 




sioDallyT by the Douth ; twice or tlnce daily, as circumstances may 
»eem U> requiro. It is not necessary to pass tlie instrimjent complelely 
down t€ tlia slom^tcli \ it i& eiiciiii^^b that ils e:iLremiiy is placed fairly 
beyond tbu wuHLid, And, ^jf tiiatse, th« ptueauLiuu 
is not Qoglc^ottid of aBcortuiaing liiat Vidgmcnt io 
rightly accompliabed, ere fluid Doiirishm<^Dt is begun 
to be introduced. One very obvious objection Ut 
tlie perniMiient retention of a tube, wbi^ther pasBed 
by llie mouth cr by the noae, is that its extremity, 
jiri^Sfting agniusL the jioKteriur pari of tie wiudpijte, 
in ftpt to occneion ulceration thoro, which may per- 
forate ; coniplJcaling the case untowarHly, by the 
establishment of tracbeal fistula. Should this occur 
— as has liuppened — the ordinary lest of the tube 
being riglitly placed viW probably fail ; air, In expi- 
ra[iu[], escaping by tbe tube i[L ihe ujuuplia^a, as 
wcW afi "by the natural outlet- 

Tlu'onghout lh« whole cnre, ihe state of rcBj^i- 
raCian must be sedulously ^fatctLCii. And sboidd 
tbn'aiening of suffocation Fiipervene — as is not un- 
likely — and prove of such a nature or not to be 
^'*^ ^ reujoved by attention lr> tiie slate of tbe wniuid, 

trachootoray ie to bo had rccourec to unhceiCatingly. Then ihe cauula 
being' retained in the tracheal wminH, tlie transverse aperture may be 
brouj^ht together, and treated bo as to favoar rapid union — there beii;g 
no longer any risk from internal nwelling or other cliango at that site, 
I have often Ihouglit, that in eitensive transverse wounds of tbe 
neck, iioplicaling lie wJEidpipe, however iiifictLMl, tracheotomy may 
bo regarded afi expedient at an earlier period ; that is, shortly after 
arrest of thi* hemorrliagc, and partial npproxitnation of the ^vuund ; so 
soon, iu fact, as the |Jalienl bus rallied siiflieienlly to bear the im- 
mediato effects of ilio operation- For then \ve would have it in 
our power to place and maintain the wholo track of the wound in 
perftct ap|iostUon, aod ]terha|>b Lo procure union almusL by the flrat 
iblentioii. So soon as tbu ebaem bud fairly closed, the ciLUula might 
be withdrawn, and the trarheal opening cautiontly and in"a^"ally 
closed- And thus, also, would we be more likely lo avoid the occur- 

Fig. 8L "A view irom behind of ibe ]iiryii:( of a patlutit -who aodm weeks proriDoalj 
attempted suitide, by wounding tho Tore jmrt of llir' n^k. By Bome miPTnajiflgtimeDU 
Ibfl ed^ of III y mclfliun wore kqit asiindPT; nnd Ihey iK-ntrii'pd. Tho patioDt vaa 
fudiv'i with dWHiiill breathing; tlie intplratifina wltb ran!, iun^-, and Idbqrioiis ; nnd he 
had ihrtfttoniTijr r>f RnflorntiEirL during bin cilitiirl».'<l Hlcvjk. Thi"p liymplnuu kpctb di*- 
regATddl. 111.' started up fliidduiily in the iiichl^ i^au^'tiL [\\*\Cl iS ihe pqlicnt ld Lbi! nuut 
thMl, and fall flown in a slate \it aiphyxiu, Iroiii wbiil lie coiild nrvi lie rwortrcd Thi- 
nhlprnviDim Hwlling of the rima pfl^^tii.lia i? r^inurWaMo ^ lieYnitd that, it M't-n ib« 
mtinded pjM^Qlng hetwixt th"- Ihyroid ranilflge and upiglpttis— uhii'h last i^ in a nunnfll 
atolfi."— LiaTON, EliiiiPiim, p. 432, 



^ 



POHEiaN BODIES IN THE WINDPIPE* 223 

lence of fistuloua ter»leTicy id the euicidal wound ; which, in the 
oHinary pr<:fgrtBS of cure, is nol imlikeK' to jipjvg tmublL'Somo. In 
perfonning tbc ojjeration, it wiU be es|vejicnt to raise and steady the 
wuKlpLiNfi by tuuaiiG of a huok tisi^d lil ILi; Iohct uifu^^u of the Inuia- 
vcT&c wound. 

In thdne cases wblcli recover, there h a risk of the larynx lewjm- 
ing conlnicted in ita talibre, so as seriously to inlerfpre wiih norniaJ 
respiration ; and all the more probably, if there be at the name time 
A BHtTiloUB openinp established by imperfect clnsnre of the wound. 
Sucb tahtH aic dciubllesa impromisin^'^ ; yet Hre capable of being 
brought lo a propporonH ifisiie. The contmcted passage may bo 
dilated bj bougies passed frum the mouth ; and, the normal capacity 
of the larjux having been restored, the fiBtulons o^K^mng may be made 
raw, and apjirosimaled by suture, A succcBsful case of this nature 
occurred in tlie practice of Mr. Liston.* 

Brondiotoirtif. 

Under this general lerni are comprehended the surgical Tounds 
of Ihe tiiroat — Laryn^lomy aiid Tracheotomy; made in ft long^tu- 
diual direction ; artificially i^pening the wiJidpipe, wJIb some impor- 
IttQt remedial objei^t in view. Btil before Iz^atlDg uf ihebe uperations, 
it taay bci well tti coneider briefly the varioub circumstauces which 
may demand their perfnrmanee. 

Foreign BodieM in the Windpipe. 

Foreign bodiuSi beld in the mouthy are apt to pabs into the wind- 
pipe, during biiddeii iuBpiralion — aa in 8|icaking, trying^ or la»»ghing. 
During inHpiratioDH the jjlotlia is opened ivide, and a foreign snh- 
fltance, even of considerable size, may p^^ss readily inwards. For ex- 
piration, however, & comparativtly narrow opening of ibe rima suffices; 
an aperture quite inenfficieut far the outward escape of the iBtrud- 
iug Eubatance ; and, indeed, audi er^capc is btill furlbm opponed by 
the effort to prfxliico it, whifihi impia^rig the foreign enbstaneo on 
the trachea] aspect of the rima, stimnlates that part to spnamodic con- 
tract In u. 

The foreign siibaiance may remain loose within the windpipe ; 
moving from part lo part, according' t<i the circnmalaiiceft of displace- 
ment. Or it iDiiy lodge at a particular site: — I- In ihe laryroc ^ 
lioGoming entangldd in Ihe vontricloH ; or being of Bucb form and eizo 
a*t to be impacted in tho general cavity. 2. It may hi similarly fixed 
across the trachea; pins, ;>oTtionK of glass, and other sharp flubstances. 
for example, bare been thus impacted^ 3. In either bronchus. And 
the right being the more directly conlinuons with the trachea, in that 

■ Lbton'j Elements, p. *iMS. 




FOREIGN bODlEa IN TKK WINDfirE. 

the impoctioD ib most likely to occur, 4. Or the hody, of fimull siw, 
may gravitate still lower, ami take up a lod^enl in one or other of 
the bronchin?. 5. Or it may be impacted in tlie ven' rima glottidifl. 
Thus: — a man much int^>xitated, becomes almost iiirienjiiblf, and is i 
ejek. The conteota of the stomaeb are la/ily evacoatad upwardajl 
Bod a portion of the ingesta may enter ihe nma and remain there^I 
causing snffijcalion. A piece oF potato-skin has thna proved fatal. ' 
Or, again, large subBtantea, held in the mouth, and forced downwards 
in sudden inspiraiion^ mny prove too bulky lo pass ihrougb the rima, 
&ad ]>ecomo impacted there j inevitably causing suffocatiooi unlesB 
instant relief be obLained^ either at the hand ^i Surgery, or ly the 
patient's own expulsive pffbrls. And in such a case, nnle&s the tight- 
need of impaction be great, sueceea is more likely to follow the instinc- 
tive throes, than in the case of smaller bodies within the larpis ; spaam 
of the gloitia bemg mechaoically prevented, and consequently proving 
no obetrnction. 

The symjitomB denoting" the oecTirrence of such accidents are, in 
eeneral, tolerably difllinct. If impaction have taken place in the rima, 
the Bjniptoms are those of rapid asphyxia; the patient suddenly 
eihibiling the greatest difitresB, becoming livid and swollen in the 
countenance, Blaring with bursting eyeballs, gaKping anxiously, stmg- 
gling- for breath, and speedily becoming inscnaible. When the foreign 
body has piiKsed i^dtliin the rima, the symptoms vary at-cordiiig to th© 
site and nature of ihe lodgment ; but, in all cases, they evince two 
leading charact eristics — denoting obstruction to respiration, and irri- 
tation produced in the part with whiL'h the snbslunce h in contact. 
If it be loose in the windpipe, or lodged ii^ the larynx or iijiper part 
of the trachea, the ftdlowing are the ordinary Byuiptoioa. A violent 
fit of fiuffocalive coagh immediately Buceeeds the entrance of the foreign 
body — seeming to cease, it h probable, only on Nature having been 
wholly exhausted. And, at short intervals, such parosyanin are 
renewed ; more particularly if any new movement of tlie foreign 
body have occurred. Inspiration is loud, strained, and of a bartih, 
crimpy, or sawing eoond. The voice is changed. PaJa ia compluined 
of in tbe part. A more or less eopiotis pxpectoralion of mueun lakei 
place, and sometimes of blood. The countenance ie suffused, and 
expressive of great anxiety — an expression almost pathognomoniCj 
CBpccially in the young. And the neck is stretched, with the head 
elevated and thrown back, in the position of orthopnoean Often all the 
auxiliary muficlea of respiration are found in full j'lay. It ia right lo 
remember, however, that in some caseB— -more enpeijially whtn n cen- 
siderable period haa elapsed sitice the occurrence of the accident — the 
intervals between the paroxysms may be passed in comparative quiet, 
with an alfll0^t totid abaence of flymptonis at that time. When inipac- 
Ijon has taken place in a bronchus, a characteristic tigii is indicatefl by 
auHcnltaiion — anpprcfiaion of reHpiralory sound on that bilIc, with puerile 




yORKiON BOIIIES IN THE WINDFiPE, 225 

respiration in the ojipoaite urgan, Tbe respiratory moverDeritB of the 
pariet«B of the chcHt, too, are diininished op arrehted in the uWrncled 
porL Or a EtUl more {ilaiti indication may he affordci), if the mibstance 
happen to be of mnBical cApahilily, however nide, and eo eituatcd Hmt 
tho Axr parsing by it in reHplration may evoka its pow^N of sunnd. 
Rough substancea e'>on occnHJon piiruloat diaotiarge, which pofi^Bses 
great &\\d characttristic ftelor. Sonietimea the foreign body, when 
smooth and looue, may be fi-dt diBtinctly impinging again&t the upf^er 
part of lUe larynx, during a conviibive effort at eitnisiou. 

The afTei^lciin wllh which 1hi:4 accident is most apt Ut be c;onfoUDded, 
lb ri^[nd obrfmotion <if tbe iijijier part of tbit windpipe by iiiilamimitopy 
change. !Jnt llie biatory of the two ca^s nintit necessarily be very 
different ; urgi-nt Bymptoms being in the ono case immediate, tinnceoni- 
panied wiih febrile excitement of tbe Gystem, and uften mu&[ iiUense 
at first; wbile in the othtr they are more or less gradual in their 

Acct^aion, of a credent cbaracterj and invariahlv attended with iiifimn- 
TTinUiry fevor. Also, in the ncoiilont, expiration is diflienit, while 
inspiration ih comparatively tasj ; whereas, in the diBeafie, (he pre- 
cisely opposite condition olitaina. 

That ill all cases there is a neceSJ^ty for the speedy adoption of 
meafiurcs cjdculated to eflett ramoval of the foreign body, is tolenibly 
plain. Othermse, the ri^ka to life will be neither few nor slight. 1. 
Sadden sufibcntioti may ocenr, at a very early period, hy impaction of 
the substance in tbe upper part of the larj'nx — a» already shown. 2. 
Imperfect respiration may more gradually induce a fatal issue ; in 
consequence of partial obatruction caused by tbe foreign body, and 
accumulation of nmous at the incommoded part, 3, Laryngitis or 
tracheitifi may \k excLiL-d, of funntdable character. 4. Cungeatiun 
may take pWo in the lungs ; followed perbaps by u-pflploctic disrnp- 

tions of the pidmonary tissue, or by pneumonia, or by bronchitis; and 
it is well U} remember, that a foreign body lodged in and irrilating 
Ihe bronchus, may causa ffita! disease of the lung — the site of the 
lodgment itself intact,* 5. A foreign body of small ^ize may perfo- 
rata » bronchus or bronchial tube, and lodge in the pulmonary tissue -j 
and acting untowurdly then.^, as jdl foreign substrvnctB mnst, mny caiiat- 
abnceBS, or lay the foundation for tuhercular deposit and fatal phthisis^ 
6, Or the [lassago ontwarda may be more advanced. The lungs may 
bu paflsed ibrough, and the cavity of the pleura reached ; and empy- 
ema may be the resvilt. Ko doubt, it Laa happened that yet another 
step baa been taken ; the forci^ snhstiLnce has |>erforatcd the walls of 
the cUer^t. by tedious idcerction, and be^n ditii:barged externally. And 
it has also liappened that a foreign body has been espectorated by the 
mouLh, along with purulent matler, at a long date from its introduU' 
liou. iSnt Kuuh occurrences are much too rare to warrant their ase as 
precedents in determiniug the appropriate treatment, 

• Monthly Journal, NmL'tuber l&U, p. i id. 
"J 



a 



226 



ponnn bodies ts tee wcetinrt. 



If the viulent efiorteortbe padoitflul to fidodfip and ntrude tbo 
!i>rtign U>iT— as is n*il unlifceW— recomw mwt be lad lo bn-^ncbo- 
tomy : ani] ihrvrogh Lbe arttfiL-iiJ opening in Ibe viudpipe the tL>reE^ 
bodjr u eougbt to l>e eilracUd. Bi^^^^ pmcer^Dg Ur tliia o}>e[«tioii, 
how«v«r, tl ii well in cvsM of <!«Diparmtjv« ob^cnritj to explore tlie 
pliarynx md gotktf lu the fint instafire. Urg^ot symplcms of 
djBpD<ea, we b*ve ilreadj seen, may te (aofed by foreign «nl>siaiioes 
Lodged in titlter of thcie pUMLgiefi ; tL^nce compreesing, iiritAting, vid 
obatractiii^ tfae ur paaigB. And «xpen«nc« bw shovn that a foreign 
body, not bulky eoLtugh to cuae dangeruus conipreB6i<*n, may l^gc 
near the rima^ and exterior to it ; m&y c&Ese majiy of tbc ordinary 
■ymptoms of a foreign body within the windpipe ; and thai in muxh a 
case, while broncbotomj miifl necessarilj fail, eipnlare efforis, daly 
uded l>y the surgeon, are mo^ likely to succeed,* 

AI«o — in children especially — i^hen tlie lodgment of a small n>und 
Enbstance, snch aa a j^a^ is sospected, and when much biviichiiic secre- 
tion IB oppressing the chest, ii is well U* premipe full voailiiig, by 
means of ipeoaf^an. Along with the vitiated miictiB, tlie offending 
body has BOQjetiiDeB been expelled- 

When the foreign body is of small size, and plainly indicated by 
the symptoma lu be either loo§e in the air paf^agt', or filed in the 
upper pari of ilie luryiis, laryngoioaiy niay be ha^l ree^^urse Uk h is 
of teigj porfonnrtncc ; and, though an aperture throngh the erico-lhy- 
roid spare Le necessarily of limitei) Jimenpions, it. \a probable that 
throit;;]] Ihat space Ench a foreign body cnav be readily enough removed. 
In all other cases, however, tracheotomy, though a more troublesome 
operation, is for ubvions reasons to be preferred j the a^>ertiire is more 
free, and ihe facilitieN f^T exiraciion, b<.nh from below and from above 
the ojx^ning, are maiiifpslly^ greater. 

When the foreign pnbstnnee is loose, it is nsually expelled fennWy 
by the outward current of air, so soun us the openitioti is compleied. 
But if fixed, it mnst be sought for, and removed artificially. If Iwlged 
flbitve the opening, a common probe is the moat convenient iuslnunent 
for (jxpUiriilion. By it the sice is detected; bj it the foreign body 
luny be pushed through the rimn — U' be coughed up ■ or loosening is 
efTfcted, iidth siiliwquent expulsion through the Iraeheal wound- 
When the site of lodgment iw in the bnmchns, lon^ curved forceps — 
mch UH iccommcnded f>r txlmction of foreign matter from the pha- 
rynx and oesuphagua — are very suitable for botti exploration and 
extraction. Auscultation and percuKsion having previously imparled 
t0 the operator a shrewd anspicion of the flile of lo<l^ent, the instru- 
ment is pTLSsed diiwn nhnt, and made if pci»<ihi« to impinge en the 
foreign substaiice ; tlieii, slightly wilhrirawn, the bhulea arc o[>ened; 
and, pushing on agiun geiiily, the object is probably grasped ; if nol, 
the other forceps — opening in an opi«Bite direction — is jiimilarly 

* LASi'KT, lOfil*, p. 729, 




FOUEIGN aOElES IN THE WINDPIPE- 



227 



employed, wttb almoi^t a certwnly of succesB, The wound is kept open, 
until bleediTig- has ceasc<l ; it is then brought ttccurateiy together by 
adUeiiive planter, and adheBion hop4!d. lot. 

But tbe air-piifi8Bge may pmvw intolerant of the forceps^ and per- 
severance in ttoir uBo, seurchitig for n. foreign body might peril life by 
violent paTOKysmR of dyspofea.* In mich caseH, modem experience bas 
pointed ont a safer mode of procedure f — more especially if the forei^ 
body be of some weight, aa a stone, coin, or any piece of metaL The 
tracheal wonnd being kept open, let the patient's body be inverted, so 
as to miiko the he<ul de[>endenl ; and, if need be, lei eucciissioQ of the 
frame he hiid recourse to, so as to favour dislodgmcnt of the offending 
substance, and its descent towards Ibe larynx by gravitatiun. Arrived 
at the rima, it will not find iln ontward passage there obstructed by 
apastn, nor witi a paroxysm of dyspinea be induced ; for, the opening 
in the iractiea has llie effect of obviating this difficulty and danger. 
EHcnpe is madr; readily into the mouth, and thua extrusion is eifccted 
with both ease and e&foty. 

It'hnR been proiwseil to Biipersede bronchot<>my altogether, by the 
preceding maoceuvre. But such a proposal does Dot Bcem to be a 
prndent one. In most casct* the attempt would probably fail, and life 
be imniineutly perilled, the foreign bod\ l>ping obstructtd by tpasm at 
the rima, and perhaps becoming impftcled there. The proceeding 
le suitable oidy when the foreign body is Gcnail, smooth, and of high 
specific g^ivity ^ and seems to he in nil respects 9a(o, oidy when a 
tracheal aperture has previously been established ; and wLeu, in cou- 
*equence, irritability of the riina has been assuaged, aud accident by 
impaction there fully provided against. A case or two of accidental 
succosrtj will not suffice to overthrow the general prineiple here iiicul- 
outod. 

ll may happen that some considerable time — weeks or monibs — 
hue elapsed since introduction of Ihe foreign body, before aid is 
requested, Snch lapse of time need not deter the surgeon from o|ierat- 
ing, if other circumstancea prove favourable. For experience bus 
shown that removal of the offending matter, even at a distant dale, 
mny be suflicient to avert nil toriuns ulterior CLmKequoiices.§ 

In attempting resuacitaLioD fn>m a^^phyxia, it is necessary to mftlu- 



• Tn luinff the fon-np'S fltiflwthPBiii ia obvir>aflh' calculntod to prova of inmU wrviiu; 
Tcadtiriji^ explornJiDn \xith eu^y atiiI fJifv. In applying the fJUoraforuif it will l>o riL<-td- 
tary lo plnce IL over thi; wounrl ba wull a^ on ibe luouLb, — tioe a cuv Ly I'r. JiitiikJluii uf 

t LAwrtrr, 1063, p. 503. J NorUiCTn Jonmul, Feb. IMfi, p. Mft 

g l^n'Joii uiil ^JLiaba^(^tl MnlieiLl Journal. Au^^usL IB43, p. 73i i and L^roa*! Pmc- 
iLk'^l Surety, p. :t7 1 ■ 



'2'2» 



ASPUYXJA* 



tuiij artil^riul roMinmtinh ; jiikJ tliin in tifTt'Cted, In ordinary ciRes, 
ijjiullljLlujrt irf nir tl^rnu^h llio moiLlii or niit-trils. But vere the Hiq* 
IfbtiuliH HpftHTnmlir'iilly dowcd^ Hucli onliniiry mcaiiB would Iw likely to 
InlUto Uiit blJ»miL<i]j tMi]y, luuviti^ Itit; lungs unaffected. Under Bucb 
inmuiNhlMiffH, UiorufijrL*, uim of tivo pniceedinga ia necesHary ; u> pOHS 
a tulhi into iho wiruipipo from Lb<] mouth ; or to perform bruncbntomy. 
Th" opiinLtion of pnwtiiM^ a trnt^liciil tiilie is always difficult; and 
U^comuii i'N|>t*ci)illy w>, t'vori iit an iriaonHille palientj if the rima be 
uUufculy hltiil — an Lit lliu ouhu of miRooiUion by carbonic acid> It can 
r<m<lily l»i iinilorhtooil^ thtTofurf;, how in many cases Butb an attempt 
il woll n[j|K.ThiTiIed hy the ojy^ration. UKually lai^'ugatomy will siifiiGe, 
One OttUtion imuit bt* imrticularly i^ttondud to ; namely, to prevent 
blood friJUi oijl(-nn>^ by lhr> wonnii, Jkud accuniuhiling in the air 
Pjuimil^<Hh Atui iiltouhl [^ocli entrance liave l>een effevLed, means should 
Ih' laki-n, by mirliou applifd to ibe wmmd, lo accomplish its expulsion. 
\u ojiKdhi t>f k^uij^'enaif'u by ihe tiei'k, it is plain that bronchotomy 
oaniiol avort u Kerioiis rusull, »ud may probably fail in the attempt 
Ht n^nUHi'itiitioii, For, iJn* OHILPO of dt'ulh ih not from conatrictioo of 
tltd >^'ini]|ii|w oLi1y ; Imt by ooMr'itsiiton i^f the brain and spinal oord, 
ftud hy intrrfrri>nco with iho jn^'okr drt^iilation. And (ht^se latter 
pih-MHUHlftTU'os niny *d" ibt'iujii'hvs k* suftioicnt to pmduce a fatjd issue, 
inilopi'udouUy of dirivl inlorfvri'noo with respiration. Seldom does 
auiy dii^^ilm'ijnKnjt w'vur in tho cvrvicol vert«br». 

A bhiw on iht' Urytix may directly peril life by arresting resiH- 
Mliinu Tho rima (jloiiidis may Iv wholly shnt, (^ilher by spaan of 
the <vcbjdin^ iiuijj^'U'n or by |^aral_v&is y<C iheir antagonists — more 
pTv^l^bly by ^mmlysis \'i M the mutolir? coDcvrofd ; or it may Ve bvt 
pMrtiAUy (VobuM, yet with siicU a lumnlt and difficulty of re^intkiD 
as to tvi^ler the casv otw of ^rteai and immediate haiard. And, under 
such cit\unifttan«*, it i» plain thai the iwly prospect of relief is by 
lnw'hiH>t\^my — i^vnins th^ niiidpipe Wlow the tnjared part; the aper^ 
tUEv WiiLj* kept |>«iuloU£s ttnill the orvnu bb^ ivcvvereU, and U able to 
Ttmina ita Wv^nlt4 fucctktfhs in normal r«^4rv4i>ti- 

Ai^thtfv t^ th^ tratf'twA, by external iDJuTT, mar [rort Cila], ty 
m^d and cxtvnstve trlu(^^>etua ; tbe pn^csure of tbts ^todmaog 
ItflftkyxM nore or Ws n^^y. By MVing BMny and carty p mc t am 
ia lb« «ftctrd }>An— v*r by inoi^WMi — m maj give an ootvv^ i 
t^« xhf air« aitd to awt the duvairaed disaMer. 

Afvfte^ vt i^ Urjvji muj i>ccwf ; Unil tirit liiBhiali (t i 

giWf «r «4iBa cbMidbt Mil co ikvttleus m^tim h to 




4 



i 




ACCIDENTAL SWALLOWING OF BOILING WATER, ETC. 229 

Tlie thj/roid cartilarje^ oBsiGfd, may b*? frEictnrvd l^y extenial 
Violence, and aerbus consequeiictB etimm ; requiring juitivp antipliln- 
gislics, and perhaps tracheotomy oventiinlly. 

The Accidental Swallowing of Boiling WoUt, Aarh, or other Irritant 

Fluids, 

It is common, among the pooivr ^^laaKi^s in some locnlilicHj to have 
but one vessel, a largo kettle, to hold water for cnliuaiT purpaws — 
BometiineH cold, at other times hot, accordini; lo circumslances. A 
cbild, accustomed to have ita Ihlret aa^na^rvd fiDEti such a source, ia 
likelj to help ilself, wlwn no <iuii fltc \h iieur ; aud, lii doiii^^ ho, may 
miluLppily fill ita month with fluid of Ji boiling tompcrulure. Inetiintly 
an alti-mpt la made by the little siiQerer lo ejet-t ihe fluid ; and in llie 
backward movement of ihe Imt water, partial entrance into tbe open 
rima glottidis is not unlikely U> occur, during ihe expulsive paroxytim. 
The result ia a scalding of the air passajre, as well as of the pharynx 
and "ippiT pitrt of the ajsophttgnn ; and by hwelliug in ihe former sitw- 
atiou, dariijg the Kubseqncnt inilamriutlory profOBS, the most serioiia 
results m;ty ensne. 

Aduks may swallow acids or nthcr acrid fluids, either l>y accldeui 
or intentionally. In the latter case, the air passjige is stldom injiireil. 
The determination to the act of swallowing shijts tho glottis, and the 
flnid pa;uM.'s downwards in the gullet, alone. But if a patleuL jLceiden- 
lidly rtttempl to swoiUiw a fluid (if ihia kind, mistaking it for wm© 
other of a harmless natiirf, Ih*^ expidsive pffort is instantly made — 
as in ihe case of the child with hot water ; the glottis is opened Id the 
paroxysm, and the noxious fluirl cPfccis a partial entrance there. 

The treatment of Huch eases requires to be conducted with mi 
energy projjorlioned Lu (he urgency of their nature. Tho iiiftammHloiy 
process may not bo proventvd ; but it should bo our auxious undeavour 
to molenite and delay ita onset, and to effect ilj^ Sfieedy retrocession. 
The most active auliphlogistics are employed — immediately; bleeding 
from both part and svstem ; outward fomentation j antimony. It may 
be that hy such means the pn>gress of inflammatory tumescence may 
be rei^traincdf so as not to a6^ect respiration urgenily, and that inSain- 
mfttory oxlem^iiui from thu parts first involved to tho air piuLfAgOB in 
general! may he prevented. If, however, antiphlogihiics fail, and 
asphyxia threaten hy obetruclion in the larynx, tracheotomy is to be 
had recmirsc tu; at once; not reserving the operation^ especially in the 
cbild, until by extreme urgency of the symptoms it cannot poasihly be 
longer delated, and recovery is rendered more than problemaiical by 
oongestion in the brain, in the lungs, or in both. Laryngutomy is 
plainly nnsnifjihle; to practiRa ihnt, wunld bo to cut into the affected 
part, and to fulfil very imperfectly, if at all, the ohjecl of the operatioD. 
The wound of tracheotomy, on the other hand, is below the seat of 





230 



LABTNGITT5. 



rliHGAse) the aficctcd part lb put at rest, life ia snvcd from Asphyxia, 
and the inflamiDg larjns, hy hc'ing allowed quietude^ is pouerfully 
aided in the reBohitory effort. On decadence of the inflammatory 
proceas, and when absorption, cleariog away all swelling, haK rcelored 
the Dormal sUf^ of llie organ, tbo lube is withdrawn, and the wound 
pennitted to close. 

Spasm of the Glottis. 

It has been already stated bow broDchotomy may be highly 
available Id the case of spaamodic clofiiire of the glottis, threatening 
asphjsia; as in poisoning by carbonic add. 

Laryngisnms UtridMluty a spasmodic affection of the windpipe, act 
Dnciiiiiiuou ill childri'n, 'Uiil ocutuiunnllj met with in the ediill, may in 
its paroxysms Ihreaton suffocation ; and, in such circnmstantefl, the 
qneBlion of the espediency of bronchotomy comes to be entertained. 
In general, the operation is to he withheld, unless the circumslances 
prove extremely urgent ; and it ia then employed as a meims of palli- 
ation and proiraction, rather than of cnre. Ami more e^pedally will 
the pro^ioBia be grianlcd and unfavmrable, if there be reason to 
Vi-lipve that the t[>^i^ni4xlie nttacks aro dept^ndcnt oti irritntiun produeed 
ly structural change at a low part of the windpipe ; as by enlargement 
of the thymus gland, affection of the bronclual glands, aneurism, or 
other formation of tnmour. In one form of iiortic aneurism, when the 
tumour is small, and does not cumprefis and totitract the air paseage, 
btil aula (ju the luryi^x irrilaltngly by implication of tlio recurrent 
nerve, eautttng suffocatiTc paroxy&mR of upa^m in the glottis, it poema 
very proper to have rermiTse to tracheotomy early, with a certain ho^>e 
of relief, and a prospect of even eomethinp more than mere palliation. 
Bnt when the tnmonr is large, coraprcsHing and contracting the air 
passage, and causing continuous dyspnoea, the prospect is not Ao favoar- 
able, ajid the grounds for i^peration are scarcely sufGcienl, probably, to 
warrant its perform aniM,* 

It were out of place, in sueh a work as this, to enter fully info the 
various interesting and important affections of the windpipe. But it 
ia right to notice them briefly, in connexion with the operation of 
bronchot4>niy ; the kading features only bt^iiig atated. 



Lrortfixgitis. 

The inflammatory process, occurring in Ihe laiyns, may lie either 
chronic or acute. 

I. Acute LAitrKGiTja. a. LaTyngitii timpUx, — There ia, in this 
jiffection, more op Iobb tiirp;eecenco uf the mneoua membrane, Tiith the 
Mccuatnmed change of Heereticm — the results of a minor nmonnt of tb- 
* Hcrathly .Tonrrui], Au^. ISA], p. ISA. /Aid, FpIi. iBfiS^ p. 114. 



CTDKMA QL0TTIDC3- 



231 



inflammatory process; but tli« swi^lling is diO^used uniformly, and ni^t 
at any pari great, anil the secretion is not liable to be retained and 
accumulated ; uo pama:jsm of dyspucca threateaiug BufTocation is Ukely 
to be cauBod by such changes ; and, consequently, in tLis afTection 
the direct interference of Hurgery» Uy broncholomy^ is uuL required* 
Hedical truutment auffioee. 

b. LarifngitU (Edcmatosa. — This is the acnto (Bd*^ma GlotiidU ; 
an inflammatory prooeus stacking the Wytix, and rapidly <^ai]»iQg 
much bulging of the lining membrane by 
Berous and fihrinous infiltration of the mh- 
mucoiifi tis^c ; active congestion being 
rapiiily reache<l, and peraisling of high \i\- f^- 
tonsity. In couBcqiieace uf mich chaoji^, llie 
charaeteriatic syniptomR are soon devtloped; 
increasing dygpnreaf linble to fiaroxysmal 
exacerhution ; inspiration pro traded ; la- 
bourod, titriduious; oxpiratiou comparatively 
easy and aileiit ; aiixit^ty of 1:0 mile nance, &c. 
And bcfiidcE, tiiere \^ uhimately oQbrdciI to 
the ffirgeon a more plain indii:atinn ; infts- 
much as the cedemnloua mvelling may l>e 
felt, ou the epiglottis and glottis, by the 
finger introduce*! from the mouth ; and may 
eren be wen, on deprcssiiig the lougue 
forcibly by tho spocMlum, Practically, tbe 
disease may 1« divided into three stages. 

1. There is the condition of larjn^lia simplex ; while the affection has 
not proceeded beyond turgescence, and when there is no ohalniction 
lo breathing, but this state it quickly oveq^oesed, in most cases, 

2. Tbe characLenatic i^edematous swelling \^ forming; not difTuHcd and 
unifonn, but mainly ofTccting the gluttie aad ita immediate ncighhoar- 
bood, and cansing prominent bnl^ng there. Reapiration is mjw more 
or less imjreded; and obstruction is on the increase, '6. Breathin<: 
having been for some time seriously interfered with, and aeration of 
the blood imperfectly performed, untoward results begin to manifest 
themselves in both lungs and brain — congestion, followed by seroua 
effusion; the threatening of asphyxia is aggravated by threatened 
fnipervention of cama. Most frequently tije obviona caii^^e of death '\^ 
by the fornier event ; obatmction by mucous swelling becoming greatly 
angraented by accumulation of viscid muctins secretion, a pamxysm of 
dyspDcea iB induced; in the tutDuItuous disonkr of respiration tbai 
eELSues, it is not improbable that the patient muy drop asphyxiated ; 
And recovery ^om that state will be serioualy afiuct4.'d by the cerebral 
change already in progresfl. Tn other oiiReH, the fatal isnue is more 

Fi^. 85. Acute ccdcna Klottidia ; expojwd thim hehinJ. 







^^ 



(EDEMA OLOTTIDtB. 



gradual ; oaphyxiA steadily advancing, without paroxyamd aggra- 
vation, 

The Buitable treatment is nctive tbrou^^liont. At CraL orrlinary 

atitiplilogifttica art plicl iiidiistnoiiinly ; blot>d -letting, antinioii^f, ciiloinel 
ind opium- Thene may arreBt the affection in its fii"st stagp. If not, 
let them he persevered witb ; for they may jet mili^ale the Bwelling; 
preveot the occurrcnco of urgent syuipLomB, and procure a favourable 
reBolution from tlie second or characteristic Ktagc, without life havings 
beeu ever serioujily einlingereil by ihri'iLleiied aspbysiu. In ibis statue, 
however, bo it remembered, blood-letting mufrt bt had rcconreo tu witb 
very conaiJerable ctiutioo • it being well known, from exjerienc*, that 
there in an intolerance of ibis remedy^ hcrciicully employed* in all cases 
in which respiration is ticrioiisly obstructed. Let tnt^reiiry take the 
place of loss of blood ; and by it, .judiciously employed, let us hope to 
limit deposit and promote absoq^tion sucoeHsfiilly, and tbiia to umk? a 
Biitisfftctory inipression on ibe edematous bolgii^g. Not Rcldom marked 
benefit \^ill follow free fcejvrifit'atinn of the fpiglottiB and lips c»f the 
glotti-s by means of a curved knife; the ton^iie btinff folly depressed 
by the monthppeculnm, so as to render thefle parts accessible to such 
procedure. Shirtdd, howevcrj rcftolulion fail to follow on the uw of 
such meaus — the pymptoms proving both crescent ami grave — lei 
broncholomy be at oncf had recourse to; reo^anliiig the operation as 
Inily a part of th'- remedial treatnieni, whereby the jn-ril uf extreme 
urgency may be avoided, not as a biht resource A^'he^eby a lifi? half 
lost may only pcrba]>a he refrained, Traeheotoray ia plainly to be pre- 
ferred ; for thus only can we place the artifidal ojiening beneath the 
Beat of obstruction, so as lo eflectuaily avert the inimi?<lialc danger by 
impending anphyxia ; and thus only can we fulfil the very important 
indication of plrieing the affected part in the fitatc of comparative 
quietude and repose, so suited fjr facililaiing resolution and recovery. 
The niedii:al trentmcnt is not interrupted meanwhile. In due time it 
tells favourably on [he swelling. This begins to subaide ; and then 
the use of th^ tube may be begun to be discontinued, introducing ii 
only occiwionnllj. Ultimately the pjirt recuvtnj iteelf wholly aa to 
Bwelling ; and then, the tube having been finally withdrawn, (be wound 
is approximated aud encouraged to heal. Dnriii!* the fii-st hours of lhe 
tube's nse, great care is necessary in keeping the aperture clear; viscid 
mucous is being copiously secreted; the power of expectoration being 
very weak, occlusioa of the anificijil rima is apt t^i ensue; and such 
risk by midden m<physia is all the more likely lo occur, if the patieDt 
have ffllleu aaleep Khortly after performance of the operatiijn — aa often 
hapi>en9. More than one day and night may have been passed in 
sleepless anxiety, pain, and distress ; and the relief at once experienced, 
after the firet etfectJi of the tube's introduction have passed away, is 
apt to lull the relieved sufferer itilo a deep and unconscious filumbcr — 
from which it were hajd to be awakened, abruptly, only lo periab by 




cRour- 



233 



Buffocation, The ftttention of & qualified attendant muHl Tw- constant, 
la maintain deaJTUice of the liibti, uulil Llie exceasive ficcrclion of 
mucus Ii]i8 diminisbed, and the power of cxpectorition been regained. 

In this affection, then, Jet Irachentomy he had recoiirtie to, bo soon 
as it is \Aiii\i that medical treatment has failed to effect timemis reso- 
lution. Do not dt^luy, uulU buth lutigH and hialj) have been to far 
involved, OS to reudor recovciy under any treatment at that etuge 
more thjin iloulttfiih 

c. Larifngitis Fibrinosa is nsuallj combined with u corresponding 
morbid state of tlie tradiea — traoheitis fibrinoHU — constituting' Cro^tp. 
This, too^ may be conveoiently divided into three stages. ]. Again 
the laryngitis simpltx^ but *if gieater iiittiisiiy ihuu in the ijj-evious 
case, and with a marked toudency to sproftd along the miicouH meni- 

bTflue df>wnwardfi. 2. The fibrinous exiidati<m beo^in ; aggravating 
al! tlic fiyinptoins, and aifordmL^ eerioua olwtrnctiim (o breathing. 3. 
The lun^ and brain implicated^ aa iu the farmer case, by reason of 
the coniinuance of impeded respii-ation. The former organs, however, 
in tbiH cnfiij are exposed to au addiiional Bonice of danger. Tlie in- 
flammatory proceiis, by continuoan exteniiion, uiny have reochpcl tUe 
bronchial ramifications; and to thp oppresftlon of the Inngfi' play» 
otberwiHC occasioned, the miditional and serious compliealiou of hrcn- 
chitie mjiy be iLdded. 

In the first stage, medical treatment is practised, as in the corres- 
ponding period of the previona affection. There is no demand for 
bronchotoray, on account of urgency of liynipluma con- 
nected uith reap i rat in n ; and tlie sprca<ling acute innam- 
matory process is not Hkely to be limited in either its extent 
ur inlenflily, by the infliction of a tracheal wound, and re- 
tention of a foreign body therein. In the second stage, 
the eympLoms are Eiifficlenlly nr^nt lo call for any aid 
whicli our art can afford, Trutlicotomy will give a moru 
direct and frpo entrance for air p.-isfiing towarrls tho Inn^^ 
tlian thrua^h the affected (aryn\ ; and the larp'ns will be 
placed in a mate of comparalivc rest, favourable lo reco- 
very. But the same good rcfiult does n<tt follow as in ihe 
case of acme <Edema glottidis. The disease is not limited 
to the Wynx, bat has passed the site of tracheal wound, 
and is already e^itablihihed, too pmbnbly, in tbe bronc^hial 
tubes; the wound is mside— lu^t in a comparatively sound 
part, lo afford refit to the superior p>rtion of the canal — 
but in the midst of the dist-ase, affording rest to but a 
'1, and a minor part, of the disorder's seal, and iuduciug, 
'''i'mal ulimulua, an aggravation of the irhole, 
,- lowariia the lungs, but with only a donbtfnl chance of reach- 
im ; for by this time the brouchial tnbL'S are clogged with 

- 3& Exiinple or &Ue irwmbraap, in crnap. Iti evil i:oria«<|[]encefl tbtt apptrcnE. 



Fig-Sfl. 





2U 



cnoup. 



piscid miiruB, the bronctiftl memhrAn^ is iteplf »iwM1«n Lnd infiltrated^ 
the trachea is more or less obstructed bj false [nembmne, and i^Hi^w, 
indeed, peeudo-membranous exodatioii h*B extended throughout aJmoet 
the whole brvmchuJ nuoificatioos. Thua, the salatary indications are 
not fulfilled, aiul the operarioQ faib of lis expected issue. In the 
third sUge, Forgical irlcHcrraco must prove still more mariifcatly 
hopeless Tn this diseafi^, ih^rofbre, the practical iufeivuce from each 
considerations will be, that our princii^U conGdenee must be placed 
iu medical treatiueDt : that the operalioD of tracheotomy — laryngotomy 
being in all respects obviously iiiuuilable — carnot lie expeoted to 
prove of either great or frequent service, but that if it be had recoune 
U>, it ahonld be dariug th? eeconfl sta^, when plainly medical treatment 
hns f»il«d ta atrwi or mifigate — and before the tkird etagp has set in, 
rendering recovery under any circumstances all bnt absolutely hopeless. 
Recourse to thp operation may be regarded^ therefore^ as the excejitiuu 
rather ibaa the general role.* 

An operation of a simpler kind, and sometimes proiiuciive of benefit, 
has lately been advocated Iry Mr. Grtcu of New York, mid otlierft; 




namely, the direct application of nitrnte ailver, in atrong solution, to the 
Affected part- By means of a powerful tipalula, the tongue is depressed 

* I un n'^il'' ■<"*"* ^^^ lullmrily ja nnl wanting lo enfnrrc on nppn«U« praclin; 
TmniKAU nn'I Brrlo'imian, for example, wtnnly a.lvf«alin;^ tho pcrfonnnhcc of tn- 
rhdoloiny in crnup, *nil HDpp«irlinff I heir ilwlHup hy an tmv of nurfwsfii] h^m^ (Brit, 
nnd fot. Ilflr. N-*. 2^, p- ll'O- lJnl."ri this i«t[nl,U»' hu-hUmii alwuv^ nblru"i« itnclf:— 
Won* Oi*"* taw mi] rjtamjplM of tnir- croup? P"f li in wrl) known htw liMiFrf-Jy jncdJciJ 
nniiiiiihlulmT IN iifinn apidicih nUfl tn. by «Mne, all sores on Uip ixnw an? oiU&l chancrM. 
dl faiinl iwi'lliii^TH 4111 Ih" brrrut il^tCH^'^"! V ^^ apppllfllinn nf sriirhu^f everr nuHpIcIoiiff 
''un^ijo i':ilLi'il ruiifi"^ ijiFriintii'L?"— m> iitH y all vi:uit klTi-ctifairi of lJm Uryni he ■rrajijj[i^l 
nmtdP thf* ^uiictaL LLr>iiiiiiilliJitir)n nf crnup. 



Kl|r n?- EiLcL nt lli<i HpnU|^'pn>b4i[i|£. fur ilie larynx ; tlie BpnUHi »]viyfl cmfUll; 
■ffliHl In whalelwii* mil tntnif bH(ll<t Uy ihv i«tulIo, 




LABVNOITIB FUBULESTA- 9-1*'* 

and brought forwanis ; a l»enl piece nf whalebone*, tipp^-fT nith sjK^nge, 
and soakfil in tEiv s^jlution (from two to four Maniples i>f ilio Nail In tlie 
oance of distilled waler) is passed behind iho epiglotlia, and tbeii 
middenl/ forcefl on into tbe laryi^x. Tbe cETect is tvofoM ; mecliaDtcal 
clearance of thy canal, ihe Bpon^e withdrawing much mncns and 
exiidatian, and tbe nitrate exciting^ a curative influence on thv affected 
m4imhriin©_ At firal, the ["resenpe of Ibe foreigii body is resented by 
unpleasant Bpasni and irritation; but these Roon snbsiJe : and the 
opentiun may be repeated at Guch inlervaJB aa circumaLaDccfi may 
fleem to re<^iure. 

But (here aru cases of ti'Ufi larynp^lie fibrinosa, in which the afi«c- 

lion i^ maiiilv Umiti'd, iiinL tie pHeudo-Tneciihraiiaus exudation entirely 
confined, lo the larynx itself. I'heiie :ire few, eortainlvi cnnipared with 
the ordinary examples of cronp; fltill lliey do cccur^ and inny be 
dia^oeed by tho aWnce of trftch<^al and pnlniiiiiary symptomSf and 
by the apparent concentration of laryngeal disorder. In BUch cases, if 
other treatment fail in the second atage, and symptoms are urgent, 
tracliooUimy shcmlJ be iiiihefiitatin^ly practiserl, on priciaely the sanje 
grounds aa ia acute (Edema — and probably with iho same fortunatn 
result- 

Diphiheriiis^ or Cf/nan^he membranaccfi^ may be said to be a Tariely 
of laryngitis (ilmnoHa, The aphchonH exiidalimi, however, and the 
affection which causes it, do nrt originRte in the laryn>, bnt in Iho 
month and faucfs, thence f*preading rapidly downwanls. Tlie lungs, 
throuf-h the bronchial ramiilcations, are early involvedj iind <?Hnnot 
possibly l>e rulieved by a tracheal nouad, Bronchotoioy, (ht-refore, is 
in this affection inadmisj^ible. 

d. Laryngitis Puriflenta.* — In this, the inflammatory proce»is in 
more advanced than in any of Ihe [ireceding forma of acute laryngitis ; 
true inilammalion \s reached, and its charHcteriatic prinliict I'xhibited, 
Fortunately such a reeidt is of comparutively rare occurrcnee } and 
fortitnately alas when it doep occnr, tlie affection in nBnftlly eonfined to 
the upper part of the larynx, and corre'sjionding portion of the fauces. 
Tho matter ie not limited in the form of nliBcess, but is diffusely 
infiltrated into the wnlfmuco'is areolar tisane. The membrane gives 
way, the matter h discharged, and an uberated t^tirface rentainK. 
The symptoms and progress are vury similur h> those of aeulo ccdema. 
And the treatment ia to be guidetl by ]irecis(dy the same principlcB, 
Ry medical treatment we hope to arrest Ihe diseape, in time to avert 
peril to life. If not, and dy(qmmft increase threateningly, tracheotomy 
is to be performed, early, in the second stage, as a part of the remedial 
treatment. The prognoaiA la favunrable- — as in oHlemH, when limeously 
relieved. 

Ar^ite ulceration of Ihe larynx may r^Hidt from thift afteotion, ah 
already staled ; almoet certain to be attended with more or less 

* Loailon Mtdical GnzHte, Jimutry \% 1833. 



236 CHROtfIC LABVNOITIS. 

«woll3iig; and conseqiKjnllj requiring the same Biirgical tud ite tlie 
acute Q»]eiim glottic! is. 

I!. CuHONic Lakykgitis. — Tills may "be the result of an acute or 
BubflCiUe attack; more frequeatly it is clmniic from the first. But, 
however ori^inalinsr* it is ever liable to srnldcn and moiUo Hp:f2;ravatioD, 
frum compiinitively nJighL caubta ; hiiiif^ing life into yciW — all ihe inoro 
itniaiaently on Jiccount of tlio msidioui^ mid <!ouipiLrativo1)' mild uiititre 
of the previous symptoms. 

a. Thicktning nf tht Murntts Membrane^ resulting from what may 
be termed Simple Cbronio Laryngitis, usually gives way to remedial 
treatmeul alone; leeches^ counter- irritation, mercury, and other aller- 
alivei. Sluiiild mi acute at:(M:»4iun Hiijiurvtne^miil to such ihe pwlitiit 
is coTiBtantly liable — obetructiun to respiration may be fipeedlly induced, 
thi^alening the most ?ierioufi conscipiencen. Under such eircnnifilttnceB, 
proportional aui^meiitation of the medical treatment may fail 1o relieve ; 
and tben tracheotomy comes to be rei|i;irtd. 

As a general niie^ when coiinler-irriialiuii is employed in any 
affection of thu laryn.v^ it Bhoiild bo Eijiplied eitlicr laifrally, or ou the 
back of the neck, not in front. Fi>r, the n^mcdiul v^cct ia the s&inc ; 
and it is ohvionsly expedient to !eave flie site of Iracheotomy cluar 
and available, in tht event of reenurse to tlial 0[ieratioD becoming 
necessary, 

b. FoUiciftar disease of the larynx is an ^iftectioji of great fre- 
qiw^ncy ; the disease bein^ resident and in mcRi ca!^os originating in 
the niucona folliclca. Thcj^^? arc flctn oa the luick of Ihc pharynx, in 
varioas stages and forms of nmrbid alleraiion — hypt-rtrophied, vesicu- 
lar» liuslular, ulcerated ; and the pri^fieiice nf similar change within 
the larynx is markeil by characleri&iic hymptouis— cough, expectora- 
tion, boarsenesa of voice, ic. If permitted to advance, the conse- 
quences are serious ; loss of voice, iuci-ease of hlruciural change iu iho 
air passages, and impairmciit of the grincral h^ulth. Treatiueat con- 
sisls in rest of the parts ; application of the nitrate of silver, in the 
manner already described, IjotTi ta the fauces an<i within the larynx i 
and alteratives internally, according to cireumslances — arsenic, iodide 
of iron, Donovan'H liquor, Ac. 

e. Chronic CEdema Oiottidis. — This affection is more gradual and 
leas marked than the acute form; but is not lesa dAng:eroua; being 
liable to swddi^n and great exaci-rbatioi*. The o?dema is gradually 
formed, of more solid consistence, and more imifDnnly diffused, Btit 
from slight exposure to cold, error In diet, or other casualty, acute 
accession is very pr<me to supervene; speedily blocking up the pas- 
sa^, and causing the most disireSGing and dangerous dy^pnma; partly 
by acute afl'eliing, partly by entanglement of viscid mucus, partly 
hj spaemodlc or utherwiso dieordertKi acliijn of tho mu»nc1ea of tbe 
larynx. Sometimes, without any ajiparent source of aggravation, a 
fit of dyapnoaa suddenly occurs ; dependent, probably, on the last 



ULCEK4TI0W OP THE LABYNX, 237 

■ 

mentioned cause — spasm. Sucb a jiatient ie never secure. One 
momenl be mny be walking abroad^ converKing^, or otherwise enjoying 
life wiih tolerable 4:Dnifort; the next be may be prostrate, Uvid» and 
Btmgglitig for exiflteace- A f&tal rt&ult, however, etMom follows the 
first of mich seizures. Minor nlUckB usually precede tlie fatal erent- 

Tbo duty of tbe iiractitioner is, by Biiitiible treatment, to arrest 
the shiggitli process, to undo the change of struclure, and to restore 
tone lo the enfeebled ByHtem ; and, by evi'ry care, to provide against 
the application of such oauHcs as are likely to induce aggravation. 
8bonld such aggrflvaijon otcur, be muBt bo on the alert- Medical 
treuCment is contiti^ied, with rt'doiibled catv and anxiety; and iho 
patient Is closelj watched, Tf the treatment prove iiDKalisfaelory — 
fits of dyspiicea continuing to recur — Irncbeotomy is certaiidy to be 
jjerforffied. Tbns only can the tenitre uf life be rendered at all secure 
in micb cases; and iben, too, ibe other remedial means mfly be ex* 
peeled to have a more wibitary ctlect on lie original disease — as in the 
ease of simple lliirkenin^. After stfcine time, the tiibo may bt with- 
drawn, and the wotuiU closed. However, proy7ioBis as to discontinu- 
ance of the tube is not &* favoiirnbU an in the acute f^rm. KeBolution 
may be slow and imperfect; the part may never wholly regain its 
normal state; perhaps respiration cannot be restored tbrttugb the 
normal passages; and the tube, coDsequeatly, may require to be worn 
rluring the remainder of life. 

d. Ulceration of Ihf. Lanptx. — The larynx is liable to ulceration 
of different kinds — the result usually of a chronic inflammatory process ; 
1. Simple ulcpratiojL may occur as a direct result of chronic laryngitia, 
or of follicular disease; er the laryns may be implicated fiecoudanly 
by ejttenflion of iilcerLitioti froui the fauces — as is not unlikely to 
happen in patients wbo huvQ tbe misfortune to Ubour under an aggra- 
vated form of mercnrio syphilis. Tlie ulceration is very liable to be 
Kiirrouuded by a'dematoiis swelling, which, by obstmclinfr respiration, 
Bcriously complicates the case, and may demand both instant and ener- 
getic measures tg save life. Aod such complication is especially apt 
to occur, if by exptisore, or utln^r t'a^l^e, au inflammatory aggravaiion 
liave supervenud on tlie previously chronic form. Or the amount of 
tedf'ma niJiy l>e ulig^ht, repj]iration may never l>e seriously imiieded, the 
ulcer may heal, and the normal calibre and function of the larynx 
may be almoBt wholly reslored- Or, on cicatrization — long delayed — 
contraction and displacement of the parts are s;ch as permanently to 
interfere mosL seriously with both voice and respiration. 

TrualLQont coDfiBte in constitutional alteratives, snitable regimen, 
cjLreful prL>te<',tion from all sources of aggravation, patient continuance 
of mo*lerate counter- irritation, and re^dated use of nitrate of silver ic 
tba affected part; and thus we ho|>B to effect cicatrisation, ere danger- 
ous lots of substance has occurred — to effect, in short, something like 
uctmil rewlution. If <t^deuia bupervcne, and life be threatened by 



J 



23S PHTmSIS LARTl^GEi. 

paroxysmal dyspncea, tradn^otomy ia imperalivoly dL-maudeil, and 
miJMt he [)erformeJ. At Ibis juncl'ire, it is indispentwiblu lo Ihe pre- 
sei-vatinn of life. But it comes t* be a quesliun, wb*?ilier its earlier 
etnijloj-menl may not be eijiedient; not lo save MfOj directly, but lo 
Have filruclure ; by placing- the In-ryn^ at reat, and m fiKjiliUuing ibe 
a,Ctioti of raui^jJiul mentis — -Aoc^leniritig cii^atrizution wbile ulceration 
is yet Ijolh limited ami BUporficial, anii tlms jireaerving unimpaired the 
im|M>rtftnt function of the organ. I would incline to the opinion that 
it is ex])c<lient lo have recourse to tracheotomy, and temporary use of 
the lube, in tboao cases of simple uloer of the laryns which threaten 
to rcHBt onliiiary rciuudirtl means, and which^ by lohB of aub&taiice, 
endanger tbo function of the piirt ; oi>er.iling before life boB been 
threatened hy Intercurrent oedema; when there ia soreness on pres- 
sure of the thyroid cartilng^e ; when pain is felt acutely, on the box of 
the larynx being nibbed laterally across the spine ^ when there is a 
sensation of rawness and BorenesH in the pjirt comphdned of by the 
putient ; when there ia decided itiid ^wt-iiliar Rctor in the breatii, wilh 
jmin ntid dlftieulty in bwalluwing, cough, and pnrulont kjhiU — occaaion 
ally strealfi^d with blooil ; and when these syoiptorEin ji^rsist nnBiibdned. 
By the o))eration, the diseased part ia put at re^t; counter- irritation 
and allcntlive trcHlment will have a much more powerful and adu- 
tary intiuence ; and R-sides, an additional opportunity is aiforded of 
upplyin;;^ remediid iia^aus directly to the ulcerated surface. From 
tho tracheal wocmil, ibc nitrate of cilrer may be ftppliud freely if* the 
dlBeaft?d niirfar-e, moro re;4dily nnd accurately tluin tbroiigh the glofti«. 
Ard thitfi, healing- may be ohliiinetl at an earlier j>eriod than other- 
wise could have iR'en possible ] the part rctf»vera irithtuit loss of sub- 
stance ; and, after a time, the tubt mjiy be finidly withdrawn^ leavinsr 
the cure L-ompleLe. \Vhtn, however, Iriichnntdtny ha^J been performed 
at aa odvniiptd periwl of th« ciumt, on actonnt cif einer^ency cnuscd bv 
fedema, the tulxi's diaeon tin nance is very nnceriain ; a falling in of 
the box uf the larynx ia too j>robable, as the result of cicatrization ; 
and in consequence, |>ermancncy of tie urtt£cial cpcnin^^ may be ren- 
dered in<]is|n^nwLble. 

2. Tuftcrcidar Ulreralion nol nnfretpiently attacks tlio windpi}« ; 
conatitntin^f^ the true Phfhinis Lnrtfngtxi. There is first aubmucona or 
mncons dejimil of tnbertde, which eofleUM, disintegriileBT and ojjens np 
the membrane in patchy chronic nkenilion. The ecrofhWs cachexy 
fttteuda; and loo frequently, also, phthlHs pnlmonaliK is co-exiatent. 
Although by no means likely to make a satisfaclory iTiipressien on sir-Ij 
a constitutional umlady, still the ordinary treatment is U> be patientlv 
employed, Tntchcolomy is certidtdy not advimiblCf aa a meana toward!* 
ticatri nation and ciire ; hut it may be had rcconrse tn as a uierp palli- 
atjve — a means of prijtracting existence — when, hy (he occurrence of 
k^ema^ life is thrcalened frum suffucalion. 

3. A discasfd state of Ute cartilage is not uufrcquent, in brol^cn 




WARTS OF THE LABYKX- 



23*) 



down mercnrio-flyphilitjc habits; aasociated witb cbronic absceaa and 
ulceration. In udvaiioed age, the cartilages become ossifiedT and may 
neon***, but IbiH which ve nuw allude ti> is a diffcrent afftction ; 
beating the Kiune analogy to benile degi^iii^nitiun uf cartilage, jm 
alberoraalouft deposit in tb<' arteritLl tieBUf, favoiirHiblc to aiiciiriHin, 
il'^efl tn the senile cnlcnreniis eomlition <jf artem!s. The cJirtilage in 
thickened^ iuduraled, cbanged in bue, and jtartially oBKified; jiortions 
die; BUjiiJiiratioii take^ place anmnd ; the miilter bursts into the wind- 
pipe, and id expectorated; a ragged ulcerated aperture remains; tbe 
disea^d portion of cartilage lonsenp, jirolrudes, u]id, having been 
wholly dclachcd^ ib cxp<:ctorattd ; the cavity which Ltld il may tben 
contract and close, along with the nlccniled iit»erture tbrniigli which it 
TDade its eacAt>e ; or addilional ftupputaliun takcH place, freah i>ortinQB 
become necrosed, and the dit*eaae is both aggravated and jirotraclt-d. 
Ln the mest favourable point of v\v\v, iirognosiM is urisalisfiiciory ; for 
cicatrization cannot lake place, wiihouL entailing such coatractitin and 
chnngt of the cunal aa mii&t Beriously and pcrmanundy interforo with 
respiration. Sometimes a dead ^wrlion of ossified oartilagf, having 
been detached, falls downwards ; and becoming impacted in a bronchial 
ramifiealionT leadn kt a fatal issue^ either suddenly by aaphyxia, or moro 
remotdy through pultiuinary disease. 

Treatment is as In ordinary ulceration of tbia part, with eapecial 
Attention to the conBtitutinnnl vice. And when an cmtrgericy^ peril- 
ling lifej doeH occur, by intercurrent o-dtmaof the larynx, tracbcolomy 
ia certainly advisjiUe; not with tbe hoi)e f'f thonuigh cure, but in order 
t<i avert immediate danger, and perhaps t^i a<jcelerHie cicatrization. If 
life contiLiue, the tube must he pejiuaiienlly worn ; for, nnder tbe most 
fnvaiimble drcuni stances, i[ is nut to be es[>ecteJ, in this affection, that 
uunaa] culibri^ and fuuctiun can l>o ro^'aincd. 

JVarh^al FUtnla is apt to result from the prei^eding affection. The 
absceBB connected ^"itb the necrosed portion of cartilage may discharge 
it-self externally, »a well as iiilo tbe windpit^, and a CKtidouH a|>erture 
ia nol mibkely to remain, Tiiis may be brougJit to heal, by the 
occasional use, UL haig ijitervalt, of heated wire. Hut let no attempt 
at cloeuro bo mude, until wc aro certJkin that the necrosed j>ortioa buu 
been fairly extrnderl, nud that no fresh Beqnpatrum is in progreta 
there ; othenvise, by confining Ibc matliT, and so causing swelling 
?ind obstmction, seriona c(tns4^quenceB to rcsiJiratiou may ensuo. 

Warts <sf the Lar^jnx. 

Wirtv excrew^enccB have Hoinetimes been fonnd growing from ibu 
lining membrane of the lamy^c^ at its upper part; and £ubd eularge- 
DienlH of Htniclure, pendidouB, pyriform, nud of tbo nature of poly- 
pus, have also occurred, though stilJ more rarely, Tbey necessarily 
impede respiration; and, by Icailing to an intlamuiatory accession, 




aw 



STIUCTURB OF THE WINDPIPE, 



Willi lU nti*^tj*limt iPileiuii, Uiey inuy bring life into hndden and 
imminent jeopardy* TLc vuice ia boaree, 
and iillimately lost; a hard cough, like that 
of emtip, is troublesome; and during deglnti- 
tion and ^xpocloraliim, th^ eenEatiuii ia foil 
of H fori>ign body \n ibe liiryn:c ; but the 
ui08t clarMclt'riKtic evidences iin? ibe expul- 
sion of STuall iKjrliuns of the Inmour by 
ootigliinsr, flnd Ibe seeing and fteliug JU 
upwr pari by irartfnl *iud deep esplora- 
tiuii of (lie fauces. When at» emergen*^y 
by djRpnftyfc iweiirs, traclaeofomy ia plainly 
rwitiire*i Tlin.ntgb Ibe wotmd — made more 
fTpe ihan \im\\ — the grvfltb is removed, by 
eviilsioEi OT knife. And for £ome days, »t 
Iwwl, ibe iiso of ihe iracbeuioaiy tiibe will be 
ext>^ent, \v»i iudammatory fiwclliog occur 
a1 ibe injiircd part.* 




nrs^ 



I'oinmotiiMi I'f \hU nibe is liable to oomr, ml 
v»H»>ua |x>uii^ andfivm v*ri- 
*>*« ^au»ip; Viv «y\ntn^lh«1i <*f ibe •ncmnd siAer cut 

tluwa; byrtwtr*rih'm»fteroi<^trit*lioncif ulofTs; by 

M«^^c«ik«l ^4 nWnitiiHi ; (\v n^vtvuet^ ai>d discharge 
«f |virti\ws of ranikafT^ nod i\y»ap<^iient nairowinf '^' 
tW |w^»(ri* aflrr el*wnre of ibr uloer»tPil c»v> 
ll >s il.sn>^tftil vbrtWr ^^r art may W aWc Ui rr«: r. 
lW fh^rrnal <^ibTT nx>A fmfii<^ in nQcti otscfi. I>y 
Alatati^ as in FavniW aflfivti*** W ^rWr lamvos 
*«mal*t Tho rx^vrinfteni Ka? lv**i v^atW;-}- h:l lb* 
IWVApnl r<"Boe of »*\pMi<'t^v is as yefl s«uvfly ir 

tlWJflwTft *(W »v^itM l.'i'i' TTiA\ i^rfVrfi Iv j4v»tr*i7i*»i, 

IwftTA^er,, anil wift^Hnc alk^-ist^i bi ^i»tii:L9(<d nsc- 
<^ tb^ nll>-4«^>^tV1*n^ 1«l»^ *if f"!! ?A»r; and b\ n^re- 
n>Wn£ aItM^l^'«« »o kf^> K^b inbr and Tww^wa fr*e 
frrtm A<N^imviUlh'tA .^f vtv»^ mtvwi, Tb^ lattw 
*a-U«iih*n nwv^ Kvome *-4 oa>;i tuTfilnn'j^i. in fviiiCTr^ 
^fw*"*-.^ -1*' tW <r*.'*Koal an^ bT\'>TiobiaI ft»j«irt>*rafte l»otij: 
Mif^ M >ft wftMibjbiy — Jvwimiiic alm^isa cutaaiNUW 




CASES REQUIRING BRONCBOTOHY. 



241 



and not resenting a tolernLly free nse of probe, fenther, spoDge, or 
other meana employed for clearing the passnife. 

Foiimiion of Matter near the Lirtfnx. 

DifFiiM infiltration of piinilent mntter niaj Inke place, deopl^-, in 
the neck; and Ihe conscciuent swelling and tension may aerioiiMly 
impede rt-Bpt ration, by encri.)ftching an the canal of the ^indiiipe. The 
proi>er remedy is free inciBion of the infiltrated part, whereby botii 
cause aij(I efltct are at once removed. Should this fail, or should the 
Bymptoms prove obscure so as not to warrant or even indicate iacl^^ion, 
tracheotomy in L-ertainly advisable. 

CircnmEcrJbed abtweRS may form in the vicinily of the larynx. 
And the rnks uf practice are the same ; an early evacuating incisiou, 
ifpoBiible; otherwise, tracheotomy. 



Bronehotomr/, then, is axaihhhy in the following t-a&es ; — 1. In the 
case d( foreign bodies lodged in, or otberwisf' ohstrucling, tlie air pas- 
sagea. Extrusion, iiKlependently of 1hi» operation, may be OKjiected 
to be the exception to the gen<?ral rule. "2. In siispe/idfd animatitm; 
when we cannot otherwise effect, wilh certainty, artitiei^tl inllation d" 
ih© lungs — as will r^ircly be the cftHC. 3- la spasui of Ihc ^loKiH, 
Threatened asphyiia from cxlcmiil injury mny pLThupa depend on 
this cause — perhaps nn a precisely opposite cundition ; in either <'a8e, 
the operation is demanded lo flave life. And there is a like neeeisity, 
in the epasmodic occlusion of the glottis, which attends poiaifuing hy 
carbonic acid. In laryngismus stridiilusj we withhuld tht operation 

Eup»t of ttas eei^ond cnntHKUitii- " Tlie pacituL liail vriim jl »ma\\ silver Kuhe in an npcn^ 
in^ in hia vlndpipe tor mnay year-r It wu nri^nnlLy Ln[roilu<:ci1 on n<:counl of lon^'- 
cunClnuHl i]iM*ns« nf Ihc laiyiix. ta-ilh dremlful ^iilTiTEiif; aiul i-'rnatAnl vn;^ iif imptnclEiig 
auffixation. Ho cmlil not he nia<le Co <iif[WTJsp with the tube entirely, aa he U\K mm*- 
iliaitly on the VfOUTid oli>:^:ii^ a thre^fenin^ of rBtiim of ^n.^ poinrul ard daiigtrovfl 
SyTpptoiiiji, A Pinall one vioa iu)>?<litur'^l for that at llr»t lifted. Wt Ii'il a Tcry iriv^ulfu 
life, u^cd a vn^t qiiautily of ojsium. and m^ ^mall amonnT of t^pirituoiu li^jUnrv- Hv w^taA 
to be oui ill llie open air otcaaiuiially all ni^ht, and siiHcrifli rvjiralL-dly unilor ■llarkp of 
br«i4:liiti9. IIt nU4 uiiOvr tnalniruL i^aiii uid a^o.n\ Ui tbt bwpiu], on UL-^aiuit of 
rlicuinulic affoclirm nnil d«rflii;;td di4if»iiv*i orjjana. Hi? lAJied ocijmiiiiially lo pw-uii* 
hinkai'ir» cu^pluinSnf^ of diflicull hrFutliiog, and ataiinf^ thai \u& aitvi^r taba WJt*i tcxj itlturt. 
Hi: t-uiild artii'LiUL^ lukiublv- rttU nimn ht biifp^K-M hIUi bb lln^fT Ltic oninre uf tbn 
ailver tabe; at all dnita a pajti>f t\xt- r«^|dred Hir imwing throngb thp natimil channel. 
IjiUtrh', he u-Mid to juH'f^r frum ibreat^niii^' of juflocation, and hp iLH!d to rcli^-ve liIuiHlf 
or niL> i:au«i' iif tliif- vi^., ttit tnapLvated nnd ropy mucus which ^t ctiliD^lcd in tlMr 
trai'beo, lh«n not Hii4|torIfd tn he bi a dl'iGfliUid ^talc, >iy pur^hiTi^ llifou^rli ili^^ 4>penlit^ In 
Ub iifck, and into [he broncbi, loii^ lurkcyn' feaib'Tti; of Ihtne hi; carried a i^>od 4(«re, 
Vid Boaie aro nn^ in niv piiriaiwiun, Tbis feat he perr^rnaod wtthout caaain^ (iic 
allgblt^ cxritemcnt or coughing. Ulliinalcly, ojid aboiit IwrIvp yoorn ofliT ibo fipwru- 
•^n had bwn pi^rfonned, Iip died, princiimlly frocn dlaeajeil H^'?™."— Lihton. Vi^a 
Wrts of Sur^^cry, p, 4M. 

It 





242 



CASKS HEyUIUlNtJ BRONCHOTOMV- 



if poasiblo, and triiBt to ^neml treatment ; 3'et we tkre nwi^re th&t 
urgent circiira stance s may arise to deiD.intl ihe Inu'lieal wound, at 
least with the ho}Kj of imlliiitioii^ an<l (lerhaps with the effect of 
affording liiuc; for tlia tffL'cUial working of other remedies. In cer- 
ialii ca£«H of thoracic aneiirinmj loo, U'ken IjiryngtuI distress is 000&- 
sioned hy Irrilalion of ihe recurrent nerve, aiul threatenfi immediato 
death, Iraclieotomy is advisJible — in fiorae few c:\seB, it may be, with 
more thini the ho])e of moFL* jjaliiation. -1. In a'dmiii ifloUiditj 
chronic and acute, there is no safely hut hy oj-eraiion, so soon as tho 
fiyiu|>U>iiiti bavit Li'coLae at all urgent. AoJ, in tlie ocnte cases, there 
is goi^l hope of H^iecdy tliKconliiiuArice of ibe tLibo^ olusnre of the arli- 
fieial apertnre, and complete rcstoratian of normal reapiralvm* 5, In 
iari/Tigitts fibrinosn, the opemtion 13 as warranljible as in urgent cedem a, 
when th(3 disease ia limited to the larynx. But in most cwwh of Inio 
croup, in whicli llic wliolo windpipe with its ramifieaiitiriB is involve*!, 
0|jeraliuii luay rather be regarded as an cAcephou Uf the gi^ueral rule 
of non-intcrfcTen^i? ; in the L-nrly Htagi>^ it ia intxpeditnl, wHIo mochii- 
nieal obfllruclion to refJlur;ition ia not 3"et threatened; in the uioie 
advanced iieriod, it is likely to prove ineffifclnal. 6. In purulent 
iaryngitis^ there may bo tlie same netessily for operation, and the 
Bame prospect of a good result, &b in acnte oedema, 7, In chronie 
lariptgitU wilh thickening, the s^ipcrveiition uf ujdt'iua, llmmgh in- 
flammalcry accession, may render t'peration indispenKahle lo the pre- 
servation of life. IH, In simpU ulccriilion, the same event may oeciir 
as that just mentioned in eonitex-ion "ilh mere thickening of the 
memhrane. Or, iDdu[reridcntly of t^ueh an aecidejital cri^iis, operation 
may !« deemed eii)edicnt, to as&itJt the aeiiuu of other rtmedial means, 
and hy enft^cting early di-'iitrizatiuii to save structure and fimctioiL, 

9. In nlccralionj with tUsfiue of cartrhfjf, optTolioii ia likely to to 

required to savL* life from immediate djmgcr hy threatened asphyxia; 
but with Htlle 01 no pro^[»ect of diEcniilinn.tncc of the tube's use. 

10. lu phthisis lanjngca^ it may be &imilarlj' demanded for a tempo- 
mry object ; Bcarctdy with a hope of contributing to cure ; but rather 
HB a uieaas of prolraciion and |fl\Hia(ion, 1 L \\\ pressurt vn the temd- 
pipft caused by ihL^ formation of tumour or abeeess, or by impattloti uf 
Hwd in the (ersophagiia or pharynx — operation may be nece^Kary, if the 
uWmction to respiratioTi cannot be otherwise relieved, namely, by 
imonJ of the cause; by evneu;ition of the matter, cxtiri)ation or 
^^QtMO of the tumour, or extru^ioiL of Ihc impnelcil siilistauce. lU. 
la od Cfe^>tftf Iracheotomy is nut uufreipiently demanded to save life 

ftfphvxia \ and it may bo cxpcjicnl, at an cftrly jii^nuJ 
^^n«^^toaT<ft all such hazard, and lo favour as v.-lA\ aa pennit 
■IBwdoBure of the wtniod. 13, In glossitis, in htn- 
■■■■■ ■ t^atfjL ni jihanpnjiti». it is n^ (quired, when swell- 
rMtti, and imcontrolljLble, aa others irrt? to render fa1;d 
.^■UWtM^- l^- ^ carotid aneui'lsm of lar^ij ai^e — 





I-ABVNGOTOyy, 



24:^1 



when l)y circiimBtaiiceB wa are |ireclur!ed from speedy reconnw to deli- 
gation of tha arler}" — life may be audfl^'nlJ Ijroiiglit inlo peril, hy 
sii[)i?rventimi of the diffiinc fnnu on the circomscrilMsd, fttid consequent 
coimirt'SBioii {*f Ihu winilpipe. Broncholori)y llii'ii in t'sacntial ; nmX 
the tubo will roqniro to be worn, until by dpligation of the urtory we 
have effected snrh 'limimvion in the "bulk of the tummir as allngether 
to free the respiratory ca[ial. 15. Thoraric anrurUms, by compresaing 
and narrowing the air pa^sa^B, may FiimuUtte the re^nlts of inflamma* 
tory (Uwea^ in the larynx; aad in auch circmiiHlancea, lilllo good cftn 
be BXjHJL'ie^l froiD hronchotomy. In those casus, hoWL-ver, in wlii<;h 
the tumour la pmall» and cauaca dang^^rotis parosyenis of dyapntoa by 
epasm of the laryni ariBirg from irritation of the recnrrenl narve, the 
operation, as alri^ady stated, is certainly oi^itetliertt. 

In the great majority of ciifies, tnichefttomy is [irefcrable to laryu- 
gotomy, for obviuna re^anis. 

The passing of tub'fs into the windpipe, by die noee or mouth, has 
boon projroscil as a meana of eupcrsodtn"^ broncbotomj. But modern 
eip(?rienoe liuiitu tlieir nso to cases of uns^wndtd animation, iincon- 
neoted with iDryngeal or tracheal disease; and even then, their snpe- 
riority may come to be a matter of qucHtinn and doubt. 



The performance of this operation baving been determined on, the 
|intienl is seated on a chair, with tbe head thrown ba4.-k and steadied. 
A bngitndinal incision k made over the box of the larynx, in the 
mesia! apace; by diseection, the crico-lhyroid membrane is cxj^osed ; 
and ihrt^ugh thie an o|jening is then inAde by the knife — aa free aa ihe 
cartilftginotift btrtrndaries of the npar^e Till nUdw. There will seldum 
be any trouble by hemorrhage. 

I'rcic/ifQtoint/. 

Excepting the case of arLi£dal res^urfttioa on account of asphyxia 
nnconnected with laryngeal diseaet', tbe case of a foreign budy impacted 
ta the rima, and the case of a loose foreign body of amall Biae within 
the windjtipe, Iraclieotomy ia certainly preferable to laryngotomy. 
The patient having been placed as for the latter operation, an incision 
ifl made in the mesiid Jine of tbe lower part of tbe neck, fi-om an inch 
and a balf to two inches in length, the upj>er portion terminating a 
little abu^e the cricoid cartilage. Skin, fn.t, and fascia having besn 
divided, the commissure of tbe sterno-hyoid muscles ia cxposeil; and 
this is carefully separated by the handle of the knife. The tracheal 
rings arc made bare; detachment of the areolar investment being- 
effected by either the point or handle of the knite, according to cir- 





^44 



TBADHEOTOMY^ 



dUDstuices. Then the patient, if adult and conficioue, is directed to 
swallow saliva. WTiile llie windpipe is ren^Ier^ tense und elongited 
in the act of deglutition, the scalpt^l is made to penetrate at the l*>\Ter 
part of the woinid, with its Lack to the sletnum ; and, bj a sawing 
movement of the instrumoDt upwardB, th« n&ccBsaiy e^^tent uf tracheal 
wonnd iR cnmpleteii ; the isthmus of the thyroid, gltind being pushed 
out of harm's way, by the fioffer — iipwanis. If operation havo leen 
undertaken on account of the lodgment nf a foreig'n \tody^ no tube is 
necessary. The wound having been Diadem the foreign snbstance, if 
luow?, will h*^ espelkd al oni:c ; if not, it Ih to be sought for by probe 
and forceps, aa furtucrly etatcd. In the cnsc of diseofli'i it ifl our olgect 
to estnblish a. constant and Eufficient aperture for reapiralion, at the site 
of the wound ; accordingly a curved silver canula is introduced; and 
this is retained by tapes pas^in^ from a rin^ on each side of the canula, 
to l>e secured iM-hiud the neck. The canula is of KufScient size lo 
atone, coniplcleJy, for ibo temjjurarily occluded rinia; VitryJiigj couse- 
quently, according to Jige ; and, generally, of not mu?h IcB8 diameter 
than the trachea which rfioeiven it. Yet it should not Ih: ho Urge aa 
to press harshly on the lining memhrMne of ihe pasKage* lest ulceratioD 
be induced. The wnuiid should be of size sufficient to receive the 
canula, ^\ithant force, and yet not too freely : the cut margins should 
be conipri^hscd by the cariu!a, iiiierna] t-KcajfC of bhxrd buiJig so pre- 
vciited ; and this ubjcct Is further eontrihuted 1o by the ciinioal form 
of the instrument. To fneilitute inlroductionT the fimnla m&y be pro- 

vided nith a plu;^, the bulbous end project- 
ing — }^ in the vaginal speculum ; an idea 
for which we are indtlklcd to Dr. W. T. 
Gairdner, The [laiivnt is laid on his side, 
80 lis to rtind^r [hf v^uunJ. dependtnt^ and 
favournhlc to the rnitward escape of blood 
and niTicuK. After o (luic^ when the conical 
form of thu tube is uo longer an advantage, 
on account of hemorrhage, an instrunient 
of nniform calibre muy be BnbKtitnted, aa 
more fcuilable for respiration. And in toiscfl 
of old standing — more e*J|>ecially those in 
which the tube ia permanently retained — 



' 




Fi( W, 



a douhle canula may be used ; one portion being removed from lima 
to lime, for the purpose of being cleaned, while the other reraains 
keeping the canal constantly free. To the orifice of such au inbiru- 
ment, lo<t, it is well to allnch a valve, which opening to tbe full in 
inspiration Wves the whole space fwe, bur shutting in ex[nralioo forma 
a smaller aperture unilable for expectoration. 

The circumstance of the cannlk^a introduction being itPelf an 
efficient hemo.^Iatic nieaaa, mnterially fficilitates perfonuance of Ihe 

Fig- DO. OrJin»rj'can«lii; a, in profile; ft, tmn^vtrw nection (if orili™. 



1 



TiiAcriEOTO>ry. 





operatiou,* It is not oecesaiiry to wait fur entire cesMtion of bliied- 
ing, before openitig the wmJpipe ; no valuable time need be lost in 
steniinij}g oozing; warn 
jetfl of blood, if aiiy^ 
haviag been secured, 
the trziclicttl wound is 
tit onoc madpf And thi» 

tiibir :ks ppecililj intro- w\t.v\ 

dncetl. At first the presence of the foreign body, and of ihe Email 
ijuantiLy of blood which bus necessarilj entered along with it, is 
much resent^^d; a violent fit of spasmodic cough, threatening suffo- 
Million, ensues; but the bhvod having bepEi thrown buck, thmiif^'h the 
lubo, thiK St uf irritfltion pnaflCB off", and ciiin|»:iratIvGly cnhn reapiratioii 
is speedily established through the artificial opening. For many heiira 
— but ioi>re especially during the first few — tlie patient mnst be care- 
fully watched, lest the tube hecome obstructed by mucu!? ; and this is 
from time to time to be cleared away, by a probe srmed with lint or 
sponge, or by n feather; or Ihe double tannin may be uaed frifui the 
firat, admitting of one portion rctojuning in the wound, while the 
ofhpr is wilhilrawn Hnd eleaned occasionally. Snfh attention is par- 
ticidarly necessary, as fonuerly fitated, if the palient have fallen asleep 
after the operation. When expectoratioif is attempted, it is neccBsary 
to ditniniMh the aperture of llie ordiuary tube very considerably, by 
temporary appUtation of the finger; ho that the expired air may he 
expelled forcibly. At firai, thi^ nan-nwiiig is made by the surgeon ; 
but H<ion the j-alient bci^onies an adept in the simple manipulation. 
Should he grow tno weak to expectorate, it ia well to attempt extrac- 
tion of the mueng by suction ; by tbe mlapiation of a syringe, or by 
the mouth of an assistant — if possible. 

Ag already seen, jn some easeh Ihe tnl>e may be withdrawn, and 
the wound permanently closed, after n fow dnyn or weeka -, in other 
pfljieHj nnmiiil reflpiralion i^an i^ever be rewttired, and the tube must be 
worn duriiig the reniai;jder of life. And in these latter, it is truly 
snqmsing how Utile inconvenience is sustained ; respiration become* 
easy and silent, ami even the voice may lie re^^ainedT ao far as to atiniit 
of the patient fulfilling the ordinary duties and customs of society. 

The prominent danger of the operntion is by hnnorrhagi;. During 
the incisionn this is to be guarded Against by eaufion in the placing 
and making of them ; more espGcially avoiding the large veins which 
are often to be found in the Lower and ^ont part of the nock ; and if 

* Tte tube it a hemontntic, not anlj hy Ito pruemrs on Uio «flga of the wound; but 
alfio, nnd very impnrtantly, by freeing tbp venoiu return in the iwck, which dnrinf 
ilyspna!* h ni-coartjuily much relarded. 

Fig. 01. Cuinla, aa recommpndyl by Dr. fiairdnvr. Ffom a tttb the runnlji ; f, the 
BDd of tho p1u4c, prqji>ci^; i^ tix tuuidio i>f the plug. Ttio plug [a of cuufk irSlLdnvrn 
10 toon u the riDula hu ertBnil tba windpipct 




tu 




^^■ 




«r» 



to w 



tihmld ufeepUoe; mow ci^eebllr vfaca tkt 

fe— t<J oa aooowttt rf Jjif ■■■ ; fiir tfae MOit liUj i 

ygiimfiipn, bvumui^ waasmm ivtMia, mm olrfivwip 
q MJtMU v^ f^i^j vuz« c< the vcn iapfieaiBd, b ly ! 

It btf U«a often propoied, vith « Tier lo lender tti 
badi more ample sod m&, U perfermle the Osdica I7 
l«oe«# uvl cviaU ; diAcardiog th^ knife. Ir^coumu ia rtnimu rti far 
thk |HirpcMff lure bwii inroited br Dr. M*j«ha]l Hall, aaA odtfi. 
Mo«t pnclic«J eorseoftf, bowerer. mem tdll U> pr£t the ncAod br 

lu all ca#e«, It U obvunulj uf mnch tEDporuncv to kr«|> tbe pitiBil 
in ■!! CijiuiblQ mnd gmul temjjenmre, b> corer the voond with wame 
cIdUi uf luuie texture, ukd Ui take every otber mesofl vliick tuay Mif- 
(fral itWfiC >< liki?1v lo watiI off the irjflamiiiAUffj ftccecdoo bj tbe 
vlimnliiN of cold air din^ctly applied to tbe nuembraue — u ia tbe one 
i/f tnit throat. 

In thu chiM, o(*raliun ma> be rendered eitr^mely difficult ; b? tbe 
smiicvnt'tm uf the |^tJcin, the t:rj'ing uid siniggling which en^rge tbe 
Vitiiin, ihi' »»iji|| iii^^ of the tr^hcA, the llioited space of tbe Deck, tbe 
jjLimbur «f veiiir* likel/ lo »*c enc'wmt«r*sil, and ih^ intolerant* of Ion of 
blood im ihtf |tfirl of thu Mynt^m. The dih&ection ronst be coDdocted 
with unuHUul canthJJi ; and it U widJ, afitT exposure of the tr&chea, to 
tix it \iy mejiiiK "f a nUtit]t hfrok, bu oh al once to facililate uxl render 
\ut'Tv flafo liu? jn'rfurmaijnr i^f the iracijeal wound. tSo Boon aa thu has 
Ijeon effected, ihu ohild whuiiM U; hiMantly timieU U]>on ila facCf so afl 
Lo prevmil, lu liir ju [kmiiible, escqip i>f blood into the trachea. On 
(;uiiiiatiuo of Ihu lieuii'irhHije, the orJiEiary iKisitioti maybe rctnimed. 
xhuidJ Llki> circurjihUneeH c*f thu cmo rcndt-r tbi» expt^dient. 

lit iin>M cwtcfc, wio?ttlhe**id will lie coiihidered hifxiedieot, eicept 
during esplortttiuu hj fufcepw ufitr iho tjpemti*fn baa been peifonuedf 
'in acwuiit uf the lodgment ijf n fv>ririgij 1>ody. 



Jlronchorrit:^ or d'uifrr. 

The tonri denot<3ft iiwidling of lliu thyroid ^dand ; and ihia may U' 
"f vnriuiw kindH. \, Mrrr h/pcrtroph/ \ik comiiuin ; the onlar^'pinent 
k-inff cfiwrilmlly throhit^ »nd visry ^.-nidiiftl ; mic) nllimaUdy ninkilig 
ft InuiMlioii into llu* Hiate uf fliiTi|dt» (ntiii»nr, The wliJe gland mny 
Inj equally involved ; or tho ii^LlitiiaH ahmo ruay ciilargu. whilo the lobvs 
romahi of a latnnjil t'lianwtvi^ ; uioru fru*|iiently oiiu or other lobe \% Ibo 
nrat of the jiailial attoction; find wtrnt-dnu's lH)lh Ivbrb are involved, 



BRONCIIOCELE. 247 

wliiic the central portion remAina free. And, imlced, the Haine remarks, 
it« to tbc piirtial or general oboroeter of the swelling, ^ppb' ^^'* ''^^ other 
varieties of the aSecLioii. 2. The swelhnf,' may be [>f n cjstic nature ; 
the btroma being' analogous to the Btnicturc of simple tumour; the 
uystfl dtbcr nujueruus aEid sniaU, ur ixv/ and cupaciuuu, Jdiuate, and 
Gllvd with 0k glairy tluid- This prubably is the most freqiiunt fcrm of 
the diseoR^. .^. Tho Rimple stroma may contain a ^'eater or I^rb 
amount of raleartoux matter; piviri^much density to the tumour, which 
lA seldom then of lar^^' size. 5. The tumour may be malignant. Car- 
oiooma is rare. CeplialomOf which is net so, follows its ordinary counte, 
and priffioiiEa its usual chanu;ti-rs. 

BroQcbooelo is, in certain loonlitios, an ocdomia disorder. In tho 
Tyrol, and in the vdley of the Ithouo, it is eHj>ecially so; and there 
almfffit invariably awiiociated witli the mi condition to which the terra 
Cretinism h^is been applied. In this country, tbe disease is compara- 
tively rare, and hap|>iiy snch an unfortunate combination but Reldom 
exists. In Dcrbyslibt?, and hoill« otiier cuujitit^ both In Si^tjtland jmd 
England, Kowever, it merilK tbe ajjpellnti.H] of endemic. Thu raajority 
of the pfttipots are female ; and the cr'iinary period of invnaion in about 
the time of puberty. Tbe most promiaeiit symptom is inconvenience, 
with deformily, occaaioiiod by tbe bulky swelling. Growth is gradual 
and painless — unless in the malignant variety. The iudicationB by 
t«ucli vary according \\j the nalnre of ibsj interior. Ah tht? tumour 
©nlargoa, the henfl bccomee drHorilt?rc(l, in conaaqnonco of vonoue rclurn 
thence being interfiired with; and respimtion alan is more or lean 
seriwisly impeded, by pressure on the windpipi? — especially when the 
ce&tral portion of the gland is affected. Partinl enlargement — affecting 
but <me lohe — is apt to simiilato carolid anenrium, receiving a decided 
impuiHe trom the adjiavut vesai:! ; and careful manipulation is nec^&sary 
to arrive at a coirocL diagnosis. In :uiditlnh to the oivliuary diagnos- 
tics, it is to he borne in mind that, on degliililion being performed, a 
broucbocele will be found to move upwards with tbe birynx, while an 
aneurism remaina umtffectetl. 

I'he causes <if the disease are scarcely yet evolved from obscurity. 
Where endemic. It seenis certainly conneclt^d with habitual u^e of un- 
wholesome wat^^r a» an article of food, and hiibitnal exposure lo a 
humid atmnHi)hera; anii this cireuinslanee necessarily poesesees an im- 
portant bearing on tlie ipiestion of cure. 

Treatment. — In reference to trealrntnt, tbe examples of this ^liseiiae 
may t>e conveniently diviiied intotliree classes; those which are mei-ely 
deformilies, unseemly, and soinewbal truublesome by Ihdr bnlk ; those 
which bring life into [i^'ril, directly or indirertly, by interference with 
the brain atid lie air paftRag^s; and those which, by reajion of their 
malignant character, as tiimours, sooner or iater are fatal. These last — 
fortunately rare — are generally hojieless ibrLMighont their entire course. 
But for the second class, tlio inosl determined remeibal means may be 





248 



BR0NCHOCEI.E, 



with all propriety resorted lo. For the first, bcroica are not warrant- 
able. Ajid, furtunat?!}', the mnjorily of cases, in thie country, demand 
only the milder form r>f treatment. Iodine has long been regarded as 
the most powerfnl remedy ; and justly, iDtemally, it is administered 
\a tliB form uf iodido of pulaHbium — i»r uombiuedj as ^ilU iron, Ejtter^ 
nally, it is applied in tLs fnrm of s^dution, painted frequeTitlj on the 
swelling — or ointment, or limment,niljljed in — moderate leechin;^ haviiig 
been premised, in those cases in which continnn^nce of nutritive eacite- 
ment miiy seem to render mich a tneiLSure expedient ; onr object bemg 
to arrest growth, as well as to discuss bnlk already attained. At the 
Home lime, haliiuial expoHure lo a. dry and otherwifw i^alubriuus atinofr- 
ptere, with hobitnal ubq of sound viator — chalyhoalo if poaslblo — aro 
curative indications by no meanH to be ueglected. And such treatment 
will be carefully maintflincd, so as to prevent a tumour, originally of 
the first elaas, from lieeoming of tlie &econd^ and Kerionsly perilling life 
by interfering nitti lx»tb breathing and circiilalion. 

Central tamoursj presiwng tm the windpij^e, may be removed by 
operation, when of no groat size ; partly by oscibion, partly by do- 
ligation. By thp araljiel the ftit^^g^impnEH are freely divided, and 
turned aside ; the tnni<nir is laterdly separated from its cimnesionH, 
caro being taken to secure each arttriiil orifice by ligature, so soon Ad 
divided, and eat-h venous orifice — as far as possible — by ]ireBfiure of 
the fingers cif an aesistaut ; and huviiig pvoeetdcd as far wiib iLe 
knife, in the work of detachment, as pnulence will allow, tbc ro- 
mftindrr nf thn connpsiims are to Ijp ini^hided tightly in ligature. A 
Blrong needle la passed beneath ibo base of the tumour, the double 
ligature is divided, and each portion is tied fieparateiy, so its to straii' 
gulate the mass. Tumoiire of the isthmna have been thus removed 
Buceeesfnlly ; and it is probable that the tame principle of operation 
may sometimes bo oictonded to other Eweilings not liaiitcd to that part 
of the glarifL 

T^arge, solid bronchoceles, involvhig the whole g^Iaad, and of 
greatest bulk laterally, are not amenable to such radical cure. TljeJr 
BUe, site, and attachments prcclndi? the use of bgatiire ; and attempted 
removal l>y tbti kidfu eoiild Kcarcely fail to prove fatal by hemorrhage. 
Of Ifllc, however, an ingenious mode of ofH-'ratinn ba« been devised by 
M, Porta; founded on observing t)iat the hirge arteries which 8i]pp]y 
the thyroid gland do not enter the interior of it, but break up into 
numerous small brancbeE at the circumference, and that consequently 
bemorrhjige need be dreaded only when the exterior part of the tumour 
IS interfered with. Iteftidcs, the majority of simple bronchoceles be 
found Ui cdJihist of numerous cellular or tyatit- dtvdopment*, which 
push aside the imijier lecture of the gland, reducing that to the eon- 
dilion of a si ui pit envelojH.', on dividing which '!»*«**» moducts are 
exposed, or may be extracted without diffic >nly small 

vesseJa, and leaving behind a fieshy sao , leaving 






BRf)NCiIOCELE. 



249 



no truce of the tmnour. Accorilingly, the operation is perfonned 
ttiiB: — the mtegnQients of the neck, find nsvially also the omo-hyoid 
muscle, are divided by inciRion ; the timionr ifi cut into, avoiding the 
trunks of the tliyroiil arteries ; if any of these Bpring, they are tied or 
twistecl ; tbe espoaed cyatH aro removed by foroepa, or the handle of 
the tnife ; mori? sMid Klrnc^inrp, if it *'xist, in broken down and extmdpd 
by the same meajiB ; nnd bleeding liciving been arreatecl, the wound is 
uloBfd.* 

In hopeless cases life may be pmtraclcd, and great relief afforded, 
by BTibcutaneouH section of one or botii sterno-niflstoiil muscles, bo na to 
dimiiilKh ItD^^bn, favour out^rard growth, and relieve the tr^ichci nnd 
jngular from comprei^Biiin. In nonie eaBes nlfio, protraetion and pjillin- 
tion may be obtained by tracheotomy ; when the tlrcnnisUmeea of 
tbe cn^u are such oa to reiider llie [>erforma[ice of that operation 
practicable. 

For tbe purely cystic broncbocele, simpler meana may supersede 
the more fonnidablc operation of M. Porta. Iodine may be injected 
as in hydrocele (and to such afFoclion^ some apply 'he term hydro- 
cele of the neck), or a setou mny be used, ITie cyst ha^-ing been 
punctured, and its eonteuts evacuated^ a few threads of silk may bo 
passed through the anhstance of the swelling, and retained. It ia 
probable that the inflammatory result will lead to obliteration of 
the cystic fomiation ; bnt much care j^ necessary iu watching the pro* 
cess, leat it prove execsfiivt.', and tbroaloii asphyxia through Eiiddon 
and great enlargement of the ewelling. For the sohd tumours, the 
seton is not well adapted; it not only fails to discuss, but is ^dso ex- 
ceedingly prone to acceSerale growth. 

Tumours over the Thi/roid Glands 

Not unfrequenlly cystiii formations are found, not in the Mibirt.ance 
of the thyroid gland, but betwpeti this and the Lnlegumenl. If of 
small eizc and circumscribed, they may be disseclcd out. Those whloh 
are larj^^e may be treated by seton or injeclion. 



Enlargement of the Thyro-kyoid Bitma. 

Like other bursie, that which is Hitnated between tho hyoid bone 
and thyroid cartilage is liable to enlargement, chronic or actile ; caus- 
ing more or kss swelling, with pain, and obstruction to the raovements 
of the nect. The acute form is met by repeated leeching and fomenta- 
tion; the eSironic is appropriately treated by the local applicaliou of 
I iodine in eolntion, or hy other diaculienta. 



Brit, wnl Fnr. M^ Ciar. Rev., J»n. 1801, p, infl. 





250 UlSJiASE OF THE CERVICAL VEHTEBB^» 



Hernia Brprichnlie. 

A r&re ufFoction, bo dLlled, htia Lcun oLsorveJ iri tLo^ iaLo liuLi- 
timlly Btniiii tlio throu( in laud aad hUsLoinB^] (^ftlling. A fold of the 
lining' membrane is prolnided imlTiarda btjtw(?4?ii two tracheal carti- 
lagenf atid thus o. grtMer or ItBrt tumour, soft and comjiressible, m 
formed, accurding tc Ibe extent of protrusion. The only remedial 
iue»ii8 advisable are sucij out^said upplicjiliuri^ im ari: Uhuly, by aiTord- 
ingf external support, to nppoHo fiirther onlargcmetiL And tbo excit- 
ing cause — straining of the throat — is, of course^ to be di.scon tinned. 

DiseoMe of the Cervical Vcrtcbrt^, 

The chain of cerviuul vert4!bne, like olbcr bouea with their arlicn- 
lutingp surfaceBf in liable to disease of vanou:? klnda : — 1. Tlii; bodies of 
the vertebrso iniiy be interstitially absorbed, Tbt?]i a greater or less 
dug^ree of ciirviitura is likely to e^sue ; the heail tiaiially bending for- 
wards, with Uevialioa to one or other side ; and, not nnfretjueDtly, 
there is thickening nf tin; soft parts exteriorly, in consequencB of ft 
lihroidc inflammarory process slowly aJviiueing lliei'o- 2, Or the 
bodies of the vertcbrie arc aflttted by the reaults iff tme iiiflammatioDi 
At firHt there are tbickemng-, bardness, and tenderness ol preseure ; 
indieating: the OKtitit and |>critistitic t-Uis*^. Aftt-iwards matter forms, 
the b<*neB are eri^ideU by ulceiation, and jjortions may l>c detiiched in 
the form of seque^tnu There are pain^ swulliiig", leiidomesa vn pres- 
sure, and the other nsnal nitpis of un advancing' process of disorganiza- 
tion. More or leas deformity, by eurvatuie, nouessarily euaiies ; partly 
from change iii the bonL'», partly fmia n wat^tud and paralyzed etato of 
the extensor mnRclen. As can ho reiulily iinderstoiid, d4*glnl:lion is 
early and much interfered ^\i(b ; mid by encroachment on, and involve- 
meut of, the cervical nerves, serious results ai-e likely to occur, as 
regards refipi ratio D. Tlie functions of the mi^-erior csLrerailics, loo, 
may be jierilled, by uCTcclioa if the brachial [ilexuH. Thu Jisi.-Jiae is 
genendly connected, iu the patient's narrativt, with external injury; 
and tlie jn^rftims most likely to l>i! affocted arn the young arid stninioiia. 
3. Or the disease nuiy originate in the articulating lexturea j ultimalely 
inJueing similarly destnictiv© residt^. 4, There ia ^'^oi>il re[iBon to 
lielieve that, not unfrequemly, such affections follow in regular suc- 
cession ; the diaea^j comiaejjciiig in inteiT^tilial ab:sor|itioii of the liones, 
adviuioiiig from absiirption lo li-ne inflflnim^ilion, atid uliimalely dia- 
organizing Imtb Iwne and joint. 

The obvious treatmcnl of Hich disease, is to etideavonr to arrest lUi 
course by leeching auil connlcr-irntalion — the latter of the graver sort 
(inoiii, or netiml cautery), and patienliy euntinued j ti> exliibit iwlide 
kjfpiitiissiimL internally, more es[>teially when taint of tbe sjstem is 
^iBpceled J lo keep th*.- part al rest", and, in the advanced cases, to 




h 



DESEASB OF THB CBBVICAL VEUTKUH-«. 

relieve tho ikfTeclod bonoB from tlic v^-ci^ltt uf tho lioodf 09 much us 
[xisiiible, 1>y m^'chjinical mfians. A Jirut imn rrxl^ liirrid in a cLriniUr 
girth on tlifi IrunSc, pauses npwarda, exc^nrVHlinff to rccoivo ike posterior 
purt of ihe lieml, and teiminatiEig over the forehejul ; anil bj a bandage 
orstra|» attaciied to the eslremiiy of tlie nxJj and paefied under the 
cldu, ihe rcniiired su(i|>uft Is affordud. All middeniiesa uf imilion m 
the ceck w eapecuiUy to bo avoided ; but indeedi in tDOBt cases, the 
patient has an iiistinotiTo dread of such riRk^ and onrefully ^arda 
a^nttt it ; turning the head Glu^'ly, and ukli the chin supported on 
the hand. In the case of disease affecting the atlaH anddentata, such 
precaution is particularly uecesriary; leat hy eudden rupture of tlie 
ligamenlonfl upparaliiB, dieiilactrnient bhould oocur, Cjiuning falal tfom- 
pression of the medulla. Sboitld matter form in cun^Ldurablc quantity, 
&nd seek to approacli the auHjice^ at (he lateral or |)0Bterinr part of 
the neck, a free and early ineision is to be made, for evacuatioD. In 
advanced cases, tlie ouly hope of t;iirL! is by anchyloBiB, 

Cheyna, The Pathology of tb« Laryna and DroncUia, Edin. 1910. Bnmfl, Surglail 
Anatjimy of the HimuI and W'k, Edin. IH'J4. Ijiwivnrn, Ui'ti. Chir. 'iVrtD^r vttL vi, 
p. 2S1. Itri'tonnoiii, Hl's IntlaQiDiJitionr^ SpeciaJca du TLmu Mu(|urux, vl en [lortiL-ulier, 
iltf la Ihphtherile, t*jni,i, 1826. Cheyn^ Vyeh of Prant. J»cl- (art, I^tyngUig), Ttfl. iii. 
Londnix. lS.'tX Ilnpnyt™!!, ainique Clin-, torn. iii. Pari*, ISU. Twer^llu, Cycl of Pr^t 
Med. tart. TkTO(it,dUraMc$ of) vol \y. Li»n<li'n» 1834, PtirlflTj Tbu SiirgituJ PatJiulogy 
.if the Larynx auil Tridiofl^ Duhliti, 1B37. Troiuflcnu ut Hi-IJm', TrailL^ ^e b PLtbi§k' 
Luryn^e, ParU. 18^17. TroiLVi^Au iLu La Tm<'tkf^ituimi% LTx|ri^ripnt:u, Nup, ^ IH4<J, 
Ley, on LarynAJflmus Strididua ; Ilt^ndcreciD, on Laryi]j;i<'imjAiSLrMhiLiir(,Mip|]tldy Juunuf, 
Jan. JS41,p. 10. Brodiis Cb*i irf Mr. llruJicl, Med. Gai-'tt*, July 7. 1H*J. WaUan, 
Lfvtures ou tlio Pitk-Hc^ uf PJiyilr^ L<iiiiliiri, I&IS, fircuo, Tr^allBE nil DlsFOitRi of ihv 
Kir Piis5as^*<, New York, 1S40. Coiirljuid, nrt. Broachofele, Dkt. of Ptart. Medicine. 
Pvirta, y>elta Malalllti o iti'lk- C^iicnzioiii dolb Ghuudi^Li Tin^uWo, Milanu, iSi'J- Tudd, 
Cvd. of AJial. auU FU>^lijlogy, an. Tki/roid gUiuii, LunHun, lO^x). 



I 



CHAPTER XIX. 

AFFECTIOKS OF THE ARTERIES OF THE NECK AKD 
SUPERIOR EXTUEMITY. 

Deh'gah'on ofiht Carotid. 

The common carotid arlertf Tiiay require deli^fitlm on account of 
anourism, ticmorrliage by ulcer <jr vround, or erectile lumonr ia Ihe 
orbiL CurotiJ anoiirism iw iiHUally eiluated at tbe n}"per part of the 
vcKHpI, noiir ihi? nn;j:lo of tLc juw ; forming a timiour thoro of th© ordi- 
imry ehariu'lers, wbicli, shmilri it becouii" cbffns^*^ migbt serionaly inter- 
f*?re with respiration. It possesses a pecnliarily of being ill surrounded 
by rejirehsing lissuefl; it ^mv3 chiefly lowa^ls the [ihanrix, and may 
iin[K'rfectly consolidu-te after operation. Souielitnes — but fortnnalcly 
compflr;tliveIy ^dJ^nll — the diseiise nfleclH lliu ijrigin uf Ibu artery ; and 
tLtn itH in to rfi- re nee wilb respiration is more Ciirly unii terioxia. Prom 
Hiidden increase nf the tnriionr — by diffiisir>n nr otherwise — immedittte 
performance of tracheotomy may be demanded to save from urgent 
tlireateiiing of asphyxia. 

The artery may be secured al one of Iwo jiniiits ; above or below 
where it is crossed by ibe omo-byoid miincle. The former situation is 
the itioro easy of ftCfc[*H, ^md iw to l>e pi'i-ffiTcd when circumalances are 
ffl-vmirtihle ; but in ea&?s of ftnenrism^ tbe tiimour will generally be 
foimd to have entronched too far on the tipper triangular s]>ace. 

The superior ojfcraliou is performed thus: — The patient having 
been pl'iced recumbent^ ttilh the fiead throwii back and turned slightly 
to tbe oppoRiie side, an incision is made tbrongb thi? inleifunienlB, 
pltflysma nyoides, and siijierficial fjiftm, extending in the direction of 
tbe inner bonier of the «ti?rno-mixsliiid miiseU-, from near the angle of 
the jaw to the level of the cricoid cartilage- The deep fascia is care- 
fidly divided, with tbe use of forceps ; cnies veins are looked for, and 
avoided ; the margins of tLe ^'onnd are held asunder by means of bent 
copjicr epatulae ; and it may be useful to relax the parts somewhat, 
by chauging the portion of the ht-ad. Tlie descendenH noni la poshed 
aside ; the common Bheuth of th*? vesm-ls having boon pinched up by 
forceps, i» oj^eaed to the requisite extent ; and cautions isolation of the 
artery is proceeded with, so as to afford ekar space for pasflage of the 
anenriam oeedle — aud no more. The needle itt passed fro"* '^^"^ out- 




DELIOATION OF THE CAROTm* 



253 



f 



m]e ; the jngnlnr vein being repressed, if netiORSary ; nnd ibna risk ]n 
aroided of injuring llic vein, or including tlie par vaj^ifi.* Uefore 
secnring the knot, especial care should be taken to ascertain tliat 
nothing but the arterial coats ia includcLl, 

The inferior ojrtiralion is more geiiemlly Huilitble in the case of 
aneuriiiia, ns alroaily cspUiined, The patient having been placed as 
before, an inriiiion uf al>aiit three indues in length, parallE) to the 
inner border of the sterno-masloiii, is be^in a little above the level of 
the cricoid cartilage- The inner border *tf the musc^ having been 
exposed, ie cantifnisly Inrned ontwards; while the st^-mo-hyoid and 
Btemo-thyroiJ muscles are displaced iii the op|f}6ile direction. The 
deep faacia is divided below the crweaiog- of the omo-hj'oid muEiclc ^ and, 
the aheath having been openedj the ojieration is completed ns before. 
The deseendena tioni, in the former cast in front of the sheath, ia here 
found inclining to the Iraclieal side of the artery. Ox\ the left side, 
the jngidar vein ia very apt to prove troublesome by overlapping; 
on the right side, it reeedea from the carotid^ to meet the stibchiviaLi 
vein. 

After tlie operation, congestion of the tnitgs, with jfs baneful eon- 
soquenceH, must be s^iarded against by use of the lancet. And, in the 
case of aneurism at the angle of the jnw, eslcrnal pressure ia to be made 
on the tumour, so as to alone for the dedciency of repressive textures, 
formerly alluded to. It is well, also, to keep the neck bent, so as to 
relax the artery. 

The arfery at its inferior part has bpen fieciired hy a tr:inaverBe 
wound ; cutting the sterno-niasloid across, upon a dircct(>r, and then 
opening the sheath in the ordinary way.-l- 

in the case of aneurism at the root of tlie common carotiil, deliga- 
Uon of the artery at ita upper part maybe practised, with a reasonable 
hope of cure. For, us fortuerly stated, the common carotid ia favour* 
ably arlapied for Brm^dor's operation. 

Deligaiion of the external aovtiiij and its branches, is required oidy 
in the case of hemorrhngc ; and chiefly on account of wound. No 
definite rules need be given ivs to the operative procedure; this must 
be giiided by the general principles fonnerly inculcated, and modified 

by the particular eircamstancefl of the case. 

Dplignlion of thf Arterta Ajton^ma ia an operation now considered 
hopeless; and, in all probability, will never Le repeated by any judi- 
cious surgeon; circumstauccB seeming to be insuperably hostile to 
Bitisfaclory occluHion of the artery at the ileii^atcd poijit. 




* From inatlfiiEiua to Ihin rule, hi an t-ar]y perio'l uf rnv profeu'lanal Ufc, 1 had tlie 
mlflfoniitu^ lo ini'luJo the par vogiim in thp iiimfie o( LIia li^liirp. Tliif it ■' fnmr cotuq- 
lotioD to know tlut tbf! accidtiit va.^ m nil prubabilHii', unLzouiPcteii witJi tUf (aiaL jamo 
of Uiecase. I rt'corcl the circiinwoine here- Uml it umybe of aw, as a bencon, ta deter 
Uld vam DEJiors from aiuiiImj inaltt-'nlion and mialup. 

t H^ROitA^^ Dul»lin Quarlerly Janmol, Ann. IS4Q. 





PET.IGATION OF TIIE SUBCLAVIAN, 



Ddigation i>f thr. StiMarian, 



This artery requirefl ligature, on accotint of axillary aneuriftm. 
Hemorrhage by wound or ulcer is likely to call lor tlie operalioa bul 
rfti'oly- 

Siirgicftllj, Iho veEfiel iB conveniently divitlftl into tbrce portiiins ; 
internal, fmm its ongiii to the inner Ix^rder of the Ecaleni; miUiTle, 
whtTe overlaid hy the nnlerior scalenus; esteraal, between Uie outer 
border i>f Ihia muBclc and the passage over the firat rib. On the right 
dde, it \a j>osfiillc to wuurc ihe artery at an^v uf theeo (jarla of itn 




hg. on. 

coiirw* ; on the left, the two last only are j>raetical>le, the internal third 
l>ein^ not mily very deeply Boflted, but in close lonlact wilh roopl 
imporlflnt [laris which can scnicely fail lo euslain smons injury in 
ihe EiittmpU On either auk-, Iha niitldle third is not desirable; there 
being riek of Rerioiibi injury to the phrenic nerve, as well oe a. probn- 
bility of nnwitisfactory occluBinn on account of the near propinftnity 
of large coHaleral branches at the deligaled point. The external third 
is prcferreii. Bnt if, in peiforming the ordinary operation on this part 
ef the vessel, the coatH appear nnsonnd^ we are fully warranted in 
cnniiously turning afsid^ thu w.'alfnus uniHcIe, and seeking upwards for 
n nior« heallliy p<)rtion- 

Deligatinn of the external third is aL-complifibed thnn : — The 
I>alicnt having been placed recumbent, on rather a high table, and the 
elevated slioulder having been forcibly deprcpsed as much as poBsible, 
an incision is made over the claviiile, throng]) the skin and pintyama 
myoidea ; extending from the aiLlerior border of the tnntcKiuB, lo a 
Lltle beyond tbe jmsttrior border of the litpmo-mafitoid. And it ib 

Fig. (13. Hjui of Lbfl relaLlre pomtiob of Lho RbbclaTiaiL irtery. in itit outer third; «, 
■ulh'laviiiri vein; h, Imdiinl plexuH of n«rv«fl; f» AtibctivEati utory i d. BrKleitiia mnrirlt-^. 
t, dap r?riecLrd- 



HELIOATION OF THE SUBCLAVIAN. 25-5 

well tc^ pull tlie Bkin di>wnwArdfl before uaing the kiiife, bo that, on 
reailieni^e, ibe wound may be more rlirecUy corre9[j'>]ultinl nUli the 
ODurau of Lhti ve^^seL A minor int-'iaion m lunde Lti U%\\ into the 6rHt, 
pftatdng along tho pneterior border of the eterno-m(i*t<«d ; iLnd the flup 
thus imlicflied is hlightly refleote<l. The cervical fa^iai** divided ; the 
extenkal ju^dar vein is looked for, and tirnied ludde; the |)OBterior 
belly of the omn-liyoid m(iy be discloped ; and then we know tlint in 
the triangular sjtace between that and the clavicle^ is contained the 
objei'L of our wnreli. The outer ed;;e nf llie hcttleiius muscle is sought 
for; ftl tba eaine time » part of the brnchial plexnH ia brought iJilo 
view ; ftud now ihe field of search in fnrther limited ; the atJery will 
be fonnd by tracing tlie border of the imiscle downwards, on a lower 
nnd mnre anlerior plane iban the portifm of the ]jlexnB exposed, 
Plaeing our finger on the tubercle of the firat rib, the iirtery is fell 
pulsating between ; ami the knife it* guided nccurdi^gly. The vessel 
having boon ceacbcsd, is caiuioualy iB*ilitiod iv the requJBilo o^tont; 
and the needle is passed from llic elavieular aj^j>ect,, s<i as to avoid 
iBJury of the vein. Before eecurinpr *he niiose, preaaiire Bhonld be 
made by the fin^^er on the incliuled texture, so aa to make nnru that 
it is the artery. In making the downward dissection, cantion i» neces- 
eivry near the i;Uvielu ; lesl, first^ ihe supra -ticapnkr artery be woundeil ; 
and, aftcr^^ardF^ Wt tho vc^ln Hliould hiiataiii injnry. Tho urtcry, if 
cut, proves troublesomp liy hemorrhage ; and, besides, the veRSf^l is 
important as a meane of eollalerfd circulation after obstruction of tiie 
main trunk. In the great depth which Las sometinies to be cneonn- 
tered in this aituatiou^ assistance may be derived from one or other of 
the atudliikry needles \s'iiich have l>een invented; but it haa no 
h&pp*^ucdf liithert^i, that the ordiu^iry ia^tronicnti in ttkilfnt he-iidfli has 
been found quite Mifficleut. In all cascB, however, difGculty is to be 
contemplated ; and in the dissection allowance must always be made 
for the Increased depth of the vessers site, resulting fi'om displacement 
of the shoulder upwards by the axillary tumour. 

To secure the Uiiddle third, a plan of incision very Bimilar to that 
juat described will saflioe. The Ghrua of the scalenus arc cut acro60 
with tbc greatest poRsibie raiilion, i^> ah tu avoid injury of the phretiic 
nerve, which may be expected towards tlie inner margin ; and the 
nooBB is applied with equal caution, to avoid, as far as poaeible, the 
arterial brancbes of this part of the veaseh 

To expose the internal llurd, on tbe right side^ let an incision be 
made a little obovo the clavicle, more anteriorly than in tho former 
O[kerations ^ and into thia a second Incision ii made to fall, alon^ tht? 
inner bordt-r of tlie i^temn- mastoid- The sltmal attachment of thi» 
muscle is then divided and turned aside, outwards. The stenio-hyoid 
and slemo-thyroid njusclcSi havin^^ been exposed, arc divided cautiously 
from Ibeir outer border, and displaced forwards. The lower part of 
the carotid me.y ihea come into view ; Ihia \e traced downwards, until 





DELIGATION OP THE AXILLA UY. 

the subclavian is reached; and this vessel is to be secured as near t& 
possible to the origin of the rertebral, bo as to afford Epace eiuugh 
between the ligature and the origin of tlie citrotid. The textures lo 
be avoided are the jiar vagum, and its recurrent brancli, the cardiac 
branches of the HympiUheiic, die pleura, and Iht vtiiii. The needle 
in posBed from bcloiv ujiwanlB, to avoid wounding the i*leura a&d 
right vena innondnnta. The operation is nni? of grt'at difficulty, and 
not auspicious crf a pTos|)eroLis ifisue^ 

The varieties of distribution to whioh the artericK of the neck are 
liable, bt-ar an important relallou to the operations just described, and 
ehfiild ever be rtnieiDbered and calculated i^pcjii hy 1)ib surgeon.* 

Dtligation of the Axillart/^ 

Modem Burgeone Beera to have almost agreed, that tliis vessel 
Bhould not be made the subject of operation, unless in the case of 
wound of iTself 1 when Ehe general principW of burgerv are lo be fid- 
fillcd, b)' eutting clown upor tho hleoJing puinl, and placing a ligature 
alxive and below the aperture- In ihe eane of aiieuritm high in the 
ann, encvoaching so far upAvarJs as to render deligatiou of tlie hnnieral 
either advisable or impracticable, tlie axillai-y, no doubt, may be 
secured ; but it is an cjisier, more feasible, and altogether preferable 
opendion, to tic the subolavijui in its csternal lliinl. 

Like the Bubclavian, the Jkxillary nrlcry in surgically divided iDto 
three portions ■ an upper, ni!dillc% nnrl lower. And supposing that we 
have determined on deligatiou of the axilluiy, in prefercDce to the 
subcla\'ian — as, pr<)bably, will very Keldoni be the caKe — either the 
luwer or thi? upper Ibird will !« selected, speing that tho middle is so 
covered and mixed up wilh other textures, an lo le almost inaccessible 
— vnih tafety. The opei-ation, a,ecordingly, is said to be cither Kuperior 
OT inferiur. 

The wuperior operalion is performed thus: — Tlie patient having 
been placed recumbent, with an ^issislaut ready to fomprcss the sub- 
claviiin In case of aceidi'iit, an iiieision is umde, ubout three inches in 
length, and of a semilunar form — with its convexity downwards; 
comnieiithi^ about an inch from ihc sUrnai extremity of the clavicle, 
and p\tendiu^r toujirds the aLTiitninu. Or a Einiilar extent <»f ttmind 
may be made, with its convexity upwards, terminaling at the aulerior 
margin of the deltoid. Tn the one case, the clavicular jH>rtion of iho 
pectorulii^ inajur is at once cut aeriiss, in the deep distectlon ; in the 
other, tlie intermuscular space is dilated. Cure must he taken to avoid 
the ct'phalic vtid and thoracicd-ncnjmialiB artery. To exp<iae the 
latter vcBscb however, is scarcely aa untoward occurrence, as it may 

* Vide QuATir on ttio ArtcritUi, villi Bpc^iak reference t» Uila buUJkL For the 0a- 
tlAii.4 j*r ll^luFfl ft Oifl ^M|«laviafi, nv N'^nni'^ Ameriniii .Journfll -tf MeA. Sripnn', 
.1 u1v 1^4^. 



DEL1GATIU> OF THfi ElJH£HAL. 257 

happen lo provo a convenient gTiiJe lo iLo vessel of whicL we iiTC in 
fiencch. Tbe Jeep f&scia and fat are CArefully cut thrmigli ; an<l it may 
be necessary lo turn down the upper bordtr of the pectomlis niuior. 
The vein, prohaLIj, will then be first disclojicd ; this is pressed EnwartJs 
towards tlie ribs ; luid, tin- artery having been carefully iaolated to the 
rcqiiimte extent, the needle is jtaEsed from the thoiaeic to tbe acromial 
aspect. 

For the iorerior operation^ the arm is raified from lUe Hide, with 
the hand snpinaled. In the lower i>art of the axilla, thus expused, 
the head of the humerus is felt ; and over this an ineision ia made of 
about two inches in length, rather more to the ptialerior than to the 
anterior border of ibe axlllan Then, on dissecting through fascia and 
areolar tiaaue, the axillary vein and mtdian ner\'e are Hkidy to bo 
exposed ; the Ijilt^r having bten diwpljLL't?d outwarilf, and the former 
inwards, the artery will be brought into view. The uoedle ia passed 
from the ulnar aapect. In the latcer part of the operation, it is ueefiil 
to relax the textures, by bending tJie fure-nnn. 

DtUgoiion of the /lumeruL 

The brachial or bumcra] artery may lio becured at any part of its 
course ; on account of aneurism, true or false ; on account of wound of 
tbe vessel itself; or on account of an otherwise uncontrollable homoi- 
rhago from either Iho band or the fore-arm. Tbe arm having beeu 
steadied on a convenient table with the baud aupiuated, the operation 
is conducted tbua; — 

In the upper part of tke arm, an incision of about two inches 
in length is placed over the vessel — felt pulsating — along the inner 
border of tbe coraco-hrachialis muscle ; and care is taken to avoid the 
basilic vein and internal cutaneous nerve, which may lie in the way. 
The fascia having been divided, the ulnar and interncil cutaneous 
nerves, on the inside — the external cutaneous and median nurvoB, on 
the outside — the brachial veins close on each side — are avoided; the 
arm being bent, for the purpose of relaxing these tisauesj if necessar}'- 
And tbe vessel having been isolated, the needle is passed from the 
ulnar aspect. tiometimeB tbe median nerve is superficial to tbe 
artery. 

At the middle of the ana, the inciBioa la made along the inner 
border of the hicepR muscle, which, overlapping the v*^BseI, may require 
to be raised sligblly. The nieibao nerve is lo be expected, euperficial 
to the bhHxI-vesseU ; and while Ibis nerve is displaced inwards, and 
tbe muBcio held outwartls. Die artery may be separated from its veins 
and secured. It is right to remember, however, thu-t, in thi» situatioi], 
tho inferior profunda maj bo mifltitken fur the maiii trunk ; and nltKt 
that. If there be a high diviaion of the bumcnd, oue of the Iwo vessels 



L 



J 



258 LifiLlGATlON OF THE A.ETKB1B6 OF THE rORB-AllM, 

only maj bavo been tied. Not tintil tlio surgeon hofi been fnl!y batis- 
fied on t>oth i)f t\\eiia fioinljt, abonld tlie opernlion 1>e comj^let^d. by 
approxii nation of Ihe wonud In ibe case of hi^h diTisioD, the second 
tmDk, if not close to the otLer, will be foucd either along the inner 
intenmiBcukr Beptnm, in a line with the inner condyle of the htmenja ; 
or near its iiHiial Hituation, liut deeply placed, and covered by dbreu of 
Iha bracliiidia unticua muscle* 

In the lower part of tba arm, the mediaji nerve is In be expect^ 
on the ulnar side of the artery ; but it ie seldoDi that we are called 
upon to operate in this sltufitioD ; nol, indeed, unless for wound of that 
part of the vessel. 

At the bend of the arm, false aneurism of ihe humeral is proverbi- 
ally common. If prevcnlion by molbo<lic:nl j^rcsaure iiavc fnilcd, tbo 
sao is to be ont into, atid the vcsh^I R^cnt^d by ligatnre above and 
Wow the njierture, iri recent caRcs. In tumours of old standing, deli- 
gation of the bumeralj near it^ middle, is a shnpler and equally eScc- 
tual operation. Varicose aneurisai, occurring at tliis site, requires the 
same treatment ns the ordinary form of luuiunr. For aneariamal 
varis, BUppt»rt by careful bandji^ng ifi usually sufficient. 

Df^Iiffa/'on fifthe Artmtts of ihe Fore-ant}. 

Deligation here is Eeldiiio if ever required, except in the case tif 
hemorrhage from injui^ of the artcriea themsehTs ; and then it is siifli- 
cient to dilute the existing wound, and to wcuto the bleeding point, or 
points, in the iisiint i\jiy. For pccondnry Ifloerlin;"^ in the palm, liga- 
tnre of both uhiiir uiid radJAl would not sufGce; (he interossoons miist 
ftlso be secured. And, instead of this tl^recfold aud difficult operation, 
it IB infiintely better it once to perform that which, while much sim- 
pler, is equally effectiial — deligaiion of :he humeral a little below ila 
middle. 

The mdial and iilimr arteries are most «a£ily reached at the lower 
part of the fore-arm. For the radial, an incision is made on the ndial 
side of the flexor carjn radialis. For Iht^ ulnar — made njore sn|}erficial 
by bending back the baud aud fingers'* — the wound is placed on the 
radial side of the Pexor carpi nhiaris. Near the elbow joint, 1 he vessels 
can be eiposed only through a great llicknchs of moacular tifisue. The 
pmlongalion of tlie mdial, betw<?pn the meliieaqm) boncE of the thumb 
and fore-finger, may be exjxised by an incision on the ulnar aBiMct of 
Ihe extensor secnndi inlemri'lii i^oilicis. 

Woumh "ffhe Palmar Arch are apt to l-e troublesome by bleeding, 
both primarily and secondarily- In reoejil wounds, all bleeding points 
fchouM Iwj Hccnreil by ligaliire ; dilatation being practiced, if necessary, 
and moderate prosaupo uff^^rwanlB appliml. Fur bleeding occurriner 

• WAn.ATflTfE, Brit, nnd For. Med, ChEr. Rtv, Jnlv leia y. SfJS. 



WOUNDS OF TBE PALMAIl ARCR- 



250 



n(^r the TiLpM of somu days, exposure of the wtiundf witli ikpplic^aion 




j-ii!. '.a 



of oncrj^tic proaaure, should be had recourst- lo; aiid it lUiti iiiil, then 
ileligAtiun of tLe Lumeral sliuuld be pmcliseili 

RjLiiuulun, Pj-nL-tical ObaerTatians, Jcc^ I>>niba, Iflll. LieLtnn, ?A. Med. and Eurg, 
Journal, voL xvi- j). MS. A- Itiinis nn titc ^iiigii:aL Anatomy oT ihi^ Ut^ad nnil Nock, 
liAin- IH^I, Diciriuh, T>iu Aufiiucli^n, Acr, Nurntforg, 1^1. M&nw im Li^ixture uT 
vVrtme^t rin-<t 18^!f. ]l>im>imij Sur^iat jVjtalooij of Iho Artericn, Ui^blin. ]H:}i'l. A> 
Ci>o[iL'r, IjiiyV n<j4fi]Ijil Heportd, vol. i. p, 03, IdSG. R. Quoin, AnAloin^r uf Ibo ArUrien, 
with lar^^ jrUtoa, Lond. ll^O' 



Fi^ nx Peli^^on nfliumcrjl, nirliftl, nii'l ulnar arlfnisn; uUn of ifio palmar pc-juaib 



i 





CHAPTKR XX. 

JVFFECTIONS OF THE BEND OF THE ARM. 

Venisection. 

Thib Httio o(>eralion — at one limt', it is to bo feared, too frequently 
(jerforraed — is conducted thua : — The pftlienl having lieen placed orect, 
Hemi-ereutf or recumbent, uccoj'dLng h^ \i In wished to wjtlidraw icuoli 
bliKHl or otlierwit^e, a li^turt* — a riband, or 
bandage, or Bmall touniiquei — is placed ou 
tho upper pari of the iirm, aud secured whli 
sufllcient tiglitnuss to an-est the venous relum, 
yet not so tightly as lo inleriere with tlio 
BTti'ruil iijfliix — !i3 indiciUed by tit \>n\nt itt 
thti wrifii. Tbc VL^ips &t iKe bcud uf the arui, 
ibim ina<Ia Unvte aud bulging'^ nre ^nitinizeil 
uilb a view to M-lectioD. A branch nhich is 
sup<.'rficial, and lar^ enough to emit freely, ia 
lo be preterred, for obvious reasons ; and, if 
|>iih74ib1e, ibe medimi oeplmlic J8 ehouen ; for 
then we are Iceb likely to interfere with tbe 
lirachiftl Hrtery, the faseJa of the fore-arm, or 
tbe cutaneoUB nerves ; and Ihufl are avoided 
Fbo risks of AnennsuiT dlfTuse iufiammatory 
intiltration, Hud neuralgic pain. But if no 
veHsel except tliat over t})e bracliljkl i^ fuund 
Buhabli; — AS nut unfreqnently bappene — ^thcn 
the ojiuration must be c^mdncted there wiili 
especial caution ; care being taken merely to 
oi^en, not to transfix the vein. The arm ia placed nearly in a middle 
posture between pronation ^ind supinntion ; and precautiims are taken 
to Hecure its being reiauicd in that poBition nnmoved, Ey the fingers 
or thumb of one haiid — ^iid it is yuAl timt llic surgx^on be ambidiixtrouji 
in thifi proceedTTig — tho vein \n steadied ; iinil, prej|a|^^ing madr ai 
tbe satoo time on the distal asjiect, spurting f ^xe is pre- 

vented. The lancet — neither loo Bpear-poin ded in ile 

Fig. H. llluitrition of vene»ciiflu t* 



m-9i. 




n 



A001DEHT8 OF VENESECTION, 



261 



blade — belli Itetween the finger and tllTimb of the olber band, is intro* 
ditcerl obliquely across the tmck of the vessel ; and by gentlo movement 
of it a siiMcient aperturt] ia made—^tliu inslniment cutting more with 
the sIiomUlt tiiiLji whh tbu pijnl, »i as tu lujjuie llic tupurfitial part uf 
the wound being «iniKiJorflb!y more free than the venous orifioe. Then 
the blood JH allowed to flow. If the stream grow aln^gifih, movement 
of the finders will tetid to its increase by forcing the conttnte of ihe 
intermuaciilar veins to the surlWe, and accelerating the general venous 
return ; bnt care must In; tiiken lo avoid any deviation from the original 
poeition of tiie lluih, ulherwiso lui ovejiajjpiu;^ of tlit^ wound by iultgti- 
mont PFill nccunj'anly follow, Tbt; desired clTuct having boon ol'tuinod, 
the ligiUiire on the arm in Rlackened and i'cmo\ed; a tbtimb is placed 
on the wuumI ; the itrm in sponf^ed and made clean; a neatly fitting 
graduated cumprefls ia appliLil ; by a bandage passed in the form of 8, 
aU is secure<l ; and the limb is placed cf'niforLably in a bent poBtnre, 
supported if nei^l be by a sling. Within forly-eif^liL hours, the bandage 
mny bo eafcly withdrawn ; but it is well to av'oiil nno of the arm for 
Home days. 

Accidertfg of Veiir^erMon. 

1, Thrombus- — By this terra is understood an aceumuklioD of 
coagulated blood in the areolar tiKBiie l>etwee[i the vein and integnmenl ; 
caufiod probably by overlapping of tbe latter; inturfoHng wiib, and 
porliaps ani'Kting, the flnw of Idooit at the timr of tbp openitlon ; pm- 
dudnff an inconvenient swelling afterwards; and not unfrequently 
inducing troublesome fiuppuratJon in and around the wound. The 
accident is to be avoided, by a auitably free opening being made at 
oiicCj and by maintenance of one psiiioti of the arm thronghout the 

whole proceeding. When (hrumbua hiia farmed, Ihe co^giibiin ehonld 
be carefidly removed, an enlargement of tbe wound lining' bml rt-eonrse 
to, if necejisary ; and then a Muitable compress is ycciirately applied, so 
as to keep the tisj^uen in close contact. 2. Nmralg'w. pains may invade 
the limb ; dependent, proljahly, on puncture of a cutanenus nerve. To 
avoid such accident, place the wound where this texture ia least likely 
to bo implicated; to en re it, dilute llie wound by Incision, and npply 
an anodyne epifhen], 3. Simple fryalppfas moy frdhiw ; and the ordi- 
nary treatment is required, 4, Angdtikuciih may occur per &f„ or in 
conjunction with ihe preceding affection. There is nn jieculiarily in 
tbe treatment, 5. Not uiifi-cquently, diffuse jH^flwrntr^ajn occurs beneath 
tba fascia, which Las probably been injured hy puncture. Free incimon 
ia imperatjvcU' neceavnry i other^^ise serious results, both loeal and 
conetitutLouab are almoiit certain to ensue. G. Someliiues thiH last 
accident is jisaoeiated W'ith a superficial and simple erysipelas, or ery- 
ihema. 7. An^irismaf f"rnitrt''^iis have been alrciidy eonpiilercd. And 
in reference to these il in v\cll lo renieiul^r, that tlio artmew of tlic 
rore-arm^ following an TinuBual eoursi^ itiay he t'ouiul quite aupcrlieinl, 





2G2 



AFFECTIONS OF THK iSUliSA OVER THE OLFCHAVOX'- 



ftnil not unlike tte ordinaTy Teiits, Hence a careful examination uf 
the part should unifnrmlj preced*; iLe porformaiice of pblelxjtomy.* 

Affections of the Bursa over the Olecranon, 

From Lhbilnal pr(?EBijrG — as in the miner — lliis Uirsa ts liable tn 
clironio enlargement, and the affection is lo be trew-teil in tie ordinary 
way ; by abstraction cf preesure, ai^l the application of discHtients. 

Acute bursitis is a frequent cansequeuce of Wows on ihe elbow; 
and is usually associated with an tryai>eIftlouH affection of the surface. 
Tn^atuient is by puncture and geEieral uutiphlugiutkH \ atid If uialtfv 
form ^itliin Uie bursa, it nboiilJ bt early ovai^imted by &ee ineision. 

X^dpwxvt, N(ruTe1I» CansidrrBtidDa mr In SaJ^eo du Bros, Pvij^ 1SI3. Abtirncthy 
on m Effecitt of CloodleltiTig, Surreal Works, vol, ii, p. 13a, 1-ond. laifL Wflrdrop un 
Bloodletting, Ac. Lond 1635, Mnrflhall llixU on ihtf Mffeols ->f Rloflaii'dinj, Loni 1^30. 



• Liitely a new varitty of iht aiieuriMnal Itfion hu been obwrrHl; the nrten- pro- 
jeoliag Its 4:utiU^DU thrtyuyh tlie it'ULindod rein, mid fonnin^ an ju>ouri^mal mc by i^uD- 
dt^n»itiuu i>r the nirolar llv^ut cAL«.-rivt Uj tliu will- Tlip dtvp nuiJid of tin: v?iii ie 
ilosely incofpnmtcU widi ihul of tlie riiH'r> ; iiii-l iht Mii>trlli:iul veuoun Hpfrture Vi toU' 
liimou* with Llie arterial suc.—Hril. and For. Mni. Cliir. Upv, A|iril 1B50, p. ;W8. 

3uiiii?tinii^ iixt, Llii» ancLiiinnial ciriuiuiiiJuiU'iii b nw islili \h\i lu^iviildalt Imt iiiib u 
de^ vein. — /Ai'i/, [i. '14Q. 



CHAPTER XXT. 
AFFECTIONS OF THE WRIST AND HAND. 

Qonglia and Tkvcal Collections. 

Oam«lia frequently furm on iJie wiial ami biick of tliu LmiJ. Wben 
Ironbleaome aB well as tinficjemly^ they may be got rid of, either by 
pressure, or by ptmutiipo of the cyst. 

CotlGctioriB of glairy fliriJ often occur lq the thec» of the flexor 
tendons in the lower [art of the fore-nnii, with or without loose bodiee 
contMiiKii; forming- a aofl bul^n^ Hwellin^, which iiRUiLliy t:cteiida 
Jilao to tho palm ; more or less stiriuusly interfering \vitU the fiinctionR 
OS well lui with lh(! Bynimetry of the limb. In tbt worst casesj it has 
latterly Iwen llio praclioe to make a free evflcuiitiiifj iiieisioti, dividing 
the iinnnljir ligament at the wrist completely through, in the belief 
that thus tension during subsequent inflLLmmatory accet^siou will be 
avoided. But es[>erience has yol to skow, tliat tbe defurmity and losa 
^ of power which result Irom coodeus&tiou and depobit among^ the 
tendons by such cure, are 1ck« than those which iittecided tliu pruvioiialy 
existing state of parts. 

AccorJin^ 1o M, Vel^ieaii, it is botb safe and eflectual to evacuate 
the contents by a trocar's puncture; and ihen to inject iodiue — aa in 
the cure of hydrocele. 

Paronijfihia. 

No afiectioD is more common than paronychia, or Whitlow ; more 
especially atuon* washerwomen, cooks, nursea, and others, whose 
fingers, by the nature of their avocations, are not only kept prone to 
the astjiimptiuK of LnHarumatory disease, but also much (■:cpom!d to the 
npplicuttoQ of its exciting causes. The whitlow varieiit both in site and 
intensity. 

1. There is (i mihl form, limited to the very surface. The finger, 
at ils point, and i^erJiaits in its whole eKtent, is intensely hot ami pj^in- 
fill, red, and Roniewbat swollen; and vesications may be in process of 
forming'- Treatment consists in leecliin;^^ fomL*utation, and general 
untiphlo^slica- Or — as lb more frequently priiciised — the purl is 
nibbed liglilly itvQr wilh iiitrato of eilver, h*i aa lo blacken and dcfljc- 
(ate the surface, HcBolution in nanilly effected ; but often not without 



IL. 



2M 



PAJtOMYCHlA. 



the formation of one or mare vcEiclea — which somelimes degenerate 
into superficial ii1<]i;rs of &□ irrilAhle character. The diectkae usually 
commencflfl at Iho root cf Lho nail, a hot and painful blush of rednees 
eurrouading this; and hence the term. In conBCtjiierce of the matrii 
of the nail. In mnwy casefl^ heing priraHTily and jtermanently afTected, 
shedding of the nuil iictMl be no unlooked-for event, 

2. A fiouiLMvbat more serious itltack is fonud to pervade tlie eiib- 
culaiwuuii areolar lisaue, as well as the ekiu j boariug Ihe Bame iinnJogj 
to the former affection, aa phlegmonone eryeSptilas does to erjthema. 
It is usasJly caiiaed hy a puncfnre, laceration, or other wonnd; with 
i^r without inoculation of irritant niftlter. The swelling, htiLt, rudueas, 
tension, itnd pain nre greater; and there is a pruneneas towards acute 
suppuration. Treatment must be proportion ally active ; ci.>pifmfl leech- 
ing, at llie sides of the finger ; i>r free pmictiiring of tbe alfecled pu-ta; 
ftcdve constitutional nntipbla^aticB ; fomentation and |>oultioe ; early 
incision, if neoil he, as in pblegmonons eiysipelw* — not waiting till 
diffuse sappumlion hna furmijd. 

3. Tile worst form is tLe must deeply seated; and, anfortunately, 
not the least frequent in occurrenceH The difieawc originatea in the 

deep fibroim textures; ^wmetiines, 
thcTo IB every roEBon to beheve, la 
the perioKtenm, or immediately ex- 
terior to it. Pain is eicruciating 
from the first. For duye and 
nigbtft Ihe patient may enjoy not 
a (uomuut's sleep, or respite from 
suffering. Tension and throbbing 
.'Lro early nnd inlei^fie ; so are the 
swelling, lieat, and redneae. The 
^' " back of the hand, and Bometiines 

p*rt of the fore-arm, are red and greatly engorged with s«rouB effueionp 
Ujtttcc furma early in the Hugcr ; deep, aud confined, and eonaeL^uently 

witli ftggnivatioQ. The con- 
stitution lahfjurft under infiajn- 
raatory fever, often severe. 
At the outset, active anti- 
^'^ phlogistica, locally and gene- 

: to 'be tmploye^— copious leeching, fomentation and poultice, 
^imlaajaf — with tlie liopc of averting suppuration. Fail- 
^.^^ M tt» nliuf to Mifforing^ ttnd no mo^n^ of averting 
I rf idtiiR, hut hy early and free inciHion. It sceme 
i-^'ai^i^tf open throughout alnn^st its whole extent, 
I ifter the ioUiction cf Guch a wound, 

kthe nunX torm uf piranycLia, dcmptifiafL 




I 




■ knrt a^cvratJvrL. 



ONYCHIA. 



265 



pain will mpidlj abnte, and in a short lime the patient will prolnbly 
be in B dctp unconscious Blumber- Free ontwai'd suppuration takea 
plact^ ; the gwelling abntcs ; bonc!^ joiiil^s and tendmib uru tsavi^d ; aiid 
the finger rGcovore, tediouKly it muy "be, but well. WithliolJ the inci- 
aion, and there comes no relief but on aponlaneotis evacuation of the 
malter; and then bones are fuund cariotis or necrosed, joints are 
opened inlo, tendons are eloughing or slouglied ; the fingera maj 
recover, in some sense, but are etifl" and useless ; more frequently, 
aujpulalion h dt-mauded sunner or later. 

In botb of iho more flevero foruis, extension to the palm ia by no 
means imfrequeni. The same prinoiples of tTeatment are to l>e fnlfilled 
there aw in the finger. But in inciKiii;^, £;are must be token to avoid, 
if pos^ble, wound of the palmar arcli. 

Sometimes the viruleat form of pamnycbia \s limited to the distal 
joint uf the finper. Theji ex.ft>liatiun of lUe corresponding iihaluni is 
extremely pfjbablo- Bnt, furtunaltly, tlio whole bono soldom comoa 
away; a portion at the articulation romaina ; and, from this, regene- 
ration may take place, with bnt little uUiniate deformity. 




Oni/ehia. 

Tbie term denotes a diseased condittiiD of the matrix of the nail ; 
the resnlt of a ch runic inflammatory procesB, indneing intractable 
ulceration. The first indications are pain, swelling, and redness, 
around the root of the nail ; and, on preSHUre bfing applied, an 
ichorous discharge oozea from beneath the cuticle at this part. The 
nail at-paratcs more and more, and ia nltimately detfl.cbed ; diRcloHing 
an nngry ulwr, of irrtgnlor margin ftnd Iflwny enrface, Bnrrounded by 
dnsky rednejw, i^ndtting a thin fiotid diacl^arge^ and the Real of intense 
pain. Usually, an aborted reproduction of the nail protrudes from 
the upper part of the sore. 

The indications of treatment are Bimple. To pluck away tho 
stunted nail ; by an escbarolic — as the potassa fu8a or nitric acid — 
to deatrtjy the morbid texture j and, on Beparation of the slough, to 
make Rin^h application to the eore as its varying state may seem to 
refiuire. In almost all cases, however, local treatment is not alone 
suflicicnt. The general health will be found greatly disordered. 
Alteratives and tonics are ni^cessary ; and, in some cases, a mild 
mercurial course is followed by tlie best effects- 
Certain cases are very obstinate, and to Huch the term Onychia 
maligna has been applied ; inappropriately, however, innBmacb as the 
Hore, however nnmanageablc, poBscsses none of the characters of true 
malignancy. In such cagee, the escharotic application most be made 
with unusual intensity; or, under chloroform, the diseased parts may 
be shiivcd oflf with a Icnife ; and if, by this means, a salisfaclory granu- 
luting surface cannot ho obtained, it ia well at oucu to perform ampu- 




^66 UNYXIS. 

tation oF the pliakni. This suaimary proMdare is sliU raore fiflpocially 
ircdic&terl, in those examples of Ihe iiu'titemtc form in vhich iLe huiM 
has bcoomu involved. 

Onycliin occurs in both toes and fingerH- OnjTLiR ia usually con- 
fined to the fonuen ^y this term is nnderstood a fanlty coiLdition of 
the murgin of the nail ; origiiml or secondary; uaiifting^ or connected 
i\1i1j, an" irritable ftingoits mre of tlie soil parts. The rout of the nwl 
nut Tinfmjneully in Biuroiindcd hy ft re*! and swollen integument. The 
genf^riLl matrix iK f^iihd ; but, ikccnsionally, onychia follows on tH« 
minor affection. 

Whetlier ihe tiall liave been originally to blame, or not, it is very 
important to n-move its injiiriuns cimtact uith llic angry sore beneath. 
For this purpose^ either mild or rude measures may be employed ; the 
fonacr in the ilrai instance. Tho nail iti mjflcued, and hiiving been 
scraped tbin, has itn (hI^p gfiulually and gently ylovuled above thp 
fnngouB granulations; and then there is interposed a layer of soft 
liiit^ or othc<r huiliiUe Kubstauce. The nail having been lbii4 pi^rma- 
nontly elevnted, the fi-eed scire abandouH its irritable charatitcr^ and 
may be brought lo beal under the oixiinnry applications. Bnl» fiiiling 
6ucb meafimes, (-jirtiiil evnlnJou uf the n^il in lu Tk.- bftd rtcuurse tu ', a 
hareh-BtM>ming r<!ineJy, but vory t'ffeclnal. Th<> nail hiiving been 
Keftendl and Ihinned us before, ibe blade of fitrimir wbarj)- pointed 
Bci&wjrs is ran up from the jioinl lo the rovit; the nail is severpd at 
thai jkirt by one stroke ; the isolnied ]K)rtiun of nail — usually about a 
qtiarler uf the whole — it* then laid luiM of by btrorig disHecting forceps, 
iiijL' blade of which is puiihi.it beneath; and by a hndden wrcucli 
ovnlHJon i3 effected. L'ulcBJi nudt-r tdihimfomi, tbo pain ii great, thon^'b 
momentary. Hat inmltice or water -dressing \n applied. A healthy 
character of ^re, generally, soon appears; and beding is not loi:g 
delayed. 

Ctflilractum cfOt€ Pedmar Fa^a, 

Tho wb<^le a^KinenruRiB may bu rigidly contracted ; or a portioi> 
only, conneetod with one or more iiutjere. When the wbide isiuvolvcd, 
jil! the fingers are rigidly bent, and (he band conse*|uently is not only 
much deformed, but almont enlirely uscIvmh. The disease is most 
IrequQnt in those who n^ the Qngers much ; and is but little anieuablo 
Lo treatment. Ohvitu^ly llic chacige depends on a elinrnic indaiama- 
lory proet*s& afilcling lh« aponenroeia ; and is to W mot in its i-arly 
stage wilh leceliing, Tuerennal friction^ Uical use of iodjne, A-c. The 
l>artial form is comuion in tb^fie of the better riinks, wbe are much 
giveij to horseback e^tertiso, nud olhcr field sjiorta. In some of these 
ciiaesj nmerdment may follow subeuuncona division of the affectci.1 




TirMOURS OF TlIK METACABPAL BONES. 



267 



portion of fascia, the fitig^r heang Bubseqiiently Btmigbtencd l>y the 
a]>|jlicfttinTi uf ft Bplint and bandagt-. 

Spastic Jitxion of the ihtnab not iinfreqnently occurs ilnring' chilii- 
liood, ill cijrnnexion vt\i\\ inU'stinal irritalioii. Il ih treiUed bj the 
Applicution vi eplint Anil LiLiiilage, trhlle by pnr^tivoB &nd nllcniliven 
the prinuc viu are icctifiod. 

Those w)]o write much are lUble to troublesome B|mBm {if Lbe 
ihuinli ; someliuies called u.-rikrs t^ramp. Treatmunt consists iti rert 
of the part, yAi\\ loi<]c« conHtitiKioiially and locally. 



Tu}iwtir& oftlte MfUtctrjidl Bi^nes and Phalottffei. 

Exostosis may occur ; hut is rare. Treiiltnent ie seldoiu if ever 
reqiiircil, the affijclion provin;^ but little troiibltfloiiu'. Ostro'CJf/ttorna 
]a more couimoii. Us trealuitnt <]<'^>cnda upon 
the bulk. If sDiiill, it is inci^od ; niid. un 
|irv»flire Iw^in^ subw*picnlly applk'il| contrac- 
tion and healing will probably ensue. Or, if 
lioed be, a setun is passed and tnnporarily re* 
lainwl ; and thus the dcsirei! obliteration w 
tffetled- Tboflo of liirge size, involving the 
whole periphery of the bono, warrant oni|jnla- 
tion of llio Jiflyctcil part* lZnrh<iH(ii'oinata 
Lavo hero their mot^L frequ<>nt eito. If Ktnidl 
and external, the tumour is dL>«eeteil off, and 
the bone left iiuinjiired. Those wliicb iiffect 
the whole l)onet re(piire amputation. Gene- 
rallf, tbo tumours are not eino^lo ; yet usually 
we ftje able to sstve w pari — and houieliuiea Iha 
gronler part — uf thiil moat iiscjful organ, the * 

hund ; the avowed nou-malignaucy of this tumour admitting of inei- 
tious being made very close to the morbid formation, SomctimeSj how- 
ever, the fiize and connesious of ths tiunuur are Ruoh as to demand 
amputation of the wbolo hand. Lattdj 1 bad occahiou to remove one 
of great tine, wej^djhig fourteen iHiuads. Frnm llie apes of tlie tumour 
roptatod and Hcrioua hemorrhage hml tak<?n plnce ; and it ^vaa satia- 
factory to find, on a careful examination after injection, that the bloocl 
had eacaped from ulcerated openings in large tmperficial veins, not 
from any degeneracy in the stnicture of tlie tumour itself. 




Other DistmeA hf Uit Metacarpal Bones and Phalcingrs^ 

ThoBO lionus are cej^eciTdly hablu to 1I14? udlATiimalory caAUidties — 

tdcur, curieti, imd nccrosin. The ordinary treatment ia to he put iu 

FIilE. 1)7- Tlit^ lar[-p eiic^liomlrnniLL rprrrrfi! lo. hi ti.n NvrLlon nuulo Iu ilmu' fiUinr- 
iLiru. Aj h, tliv u^cflrslvil Hurracr, irhcnof IIk bl^nUii^ ivni-. 



2C8 



HVPERTBOFHY OF THE FINGERS, 




force. WheDf aa » last resource, amputation is unavoidaLl^, one 
general rule sliould never be forgotten, viz., that it Ib our duty to betc 
ai4 mucb as cLrcumHtances will possiVlj jjermit — a. portioD of the origirud 
hand being a inueli better organ of prehension, than any aitificial buT>- 
fltitute, however ingeniously constructed. 

Frequently^ in couse<iucnce of whitlow, or inflammation traumatically 
indncedf it maybe in our power to retain a finger, bnt not without 

complete ancbylosiG of all 
its articulations. And, under 
each oirciimBtancoB, it chines 
to be a qnestion whetlier it 
Fig.BB- were not better to amputate 

Buch a member at once, before anchylosis and cicatrization have 
occurred; thereby not only shortening the ciire, but also rendering the 
hand much moru iiauful — cHpecially in tlie cbsg of the labouring maD, 
by whom n stiff finger is felt to be conetaatly in the way, 1 bcUove 
that (he qoeHtion la to be answered in the affirmative — in favnnr of 
amputation, Tlic thnmb, however, is in dl circumstances to be pre- 
served, if possible. Rigid or not, it proves extremely serviceable. 

Another qnestion arises in the case of a hopelessly diseased meta- 
carpal bone, whose corresponding* finger la perfectly sound. Uay the 
metacarpal hone he removed atone, or must the £nger be tAkcn ^long 
with it? The latter is the preferable practice- The finger left with- 
out its metacar^iftl bone is worse tbati nRoless, 

Two or even three metacaipal bones, when carious, may be 
remoTcd, with their corrcRpnndmg tingcra, Tbe operation is preferable 
lo aniputation ot the whole hand. For the paraiaouut general rule of 
saving 09 much ae posaible, ehoidd ever he reepectcd in such cascs- 
Rome years ago in ampntating a metaearpal hone, its liaae wm tbund 
carions, aiid also the corresponding portion of the carpal rai^- The 
latter diseased part was removed by means of a gouge ; and a most 
satisfactory cure resulted. 



H 



Hypertrophy of the Fing^s. 

This rare departure from ordinary nature has been occasionally 
noticed in young people; affecting one or more fingers; origiuHiling 
from no assignable eiciting cause; consisting of true hypertrophy of 
all tlio textunrs — bones, joints, tendons, skin, and nails; and accom- 
panied with more or lefls deformity, and loss of funL'tJon, Firm aod 
continued prosEure may moderate the nnaatural gi-owth. If not, incon' 
vcnience may bo mitigated by amputation — partial or comjdete. 




(JOMQENITAL DEFORHlTlKB OF THK HANLf. 



2on 



Congenital Deformities of ihi JiantL 

Supcrnumerorj/ Jingert are naually attached, not by articulating 
app&rata^f but bj ordinary intcgiimenUry tissues. Their ampatation 
IB accordin<,'ly very easily effected. 

Weffbcd fnfftra art? ofteo hereditary ; and in M>me |iarta of the 
country are held ia e^Ueni, Should their amendment be wished, that 
is obtained by rlingion of the abnonnal band ; great care being takvu, 
dnriDg cicatnzation, to prevent reunioD of the opposetl parts. And, 
fcr this purpose, mterpOBition of dresdug is not eaough ; it ia essential, 
as in the case of bumSf to make constant and conRidcnible pressure on 
the angle of union^ at the knuL-kles; and thia ia done by meaoe of a 
piece of curd or tape, placed and retained there. 

Club-hand^ a conditioD of the hand analiigouB to club-foot, occa- 
rionallj occurs. It is remediable, at an early nge — with or without 
the aid of tenotomy — by the wearing of Buitable apparatus. And to the 
machinist, tbo mans^ment of such cases ia usually intrusted. It is also 
the province uf that prufeBBiun t« atone, by mechanical substitutes, for 
deficient deveiopm^nt of the hand or finders. 

Vogt, de PflTflnrrhia, Viteb. 1803, WBrdruit, aa Accfmnt of some Diseaaw iif ihe 
Tdm uui Fingeri', ^., Afed, CUr. TranH. vol. v. p. 139. Dulvil, DUMfrt^tion nur U 
FuUrio, Puii, ISIA. Cni^e, rAtWto^uil Bad l'|-actiral Qtocr^atmoH dd Whiiluf, Ed. 
Uei ADil Surg. Joumfl], Apiil 1^9, p. S05- Dupuytmi, CUoiquD Cbimrtf. t. i Brt. I. 



270 



CHAPTER XXII. 

DI3EASEB OF THE AUTICUI.ATIONS OF THE 
SUrEKlUR EXTREMITY. 

Disease f/ tJie Shoiildtr-Ji'int. 

TiiiB join1, like others, is liable to the oi-dinary aflectiona of ftiidi pttrtB, 
But it is |jerhap8 especially liaMc to dieorgimizing dL-ifiiae, involving 
v^\ texinrea nltiniMltlyj art<l usually oriffinating in Uic cancel I aled tissirc 
of tlie lieail uf Oil* innueius. To (ills the It'rui Omalgia ^VHa formerly 
n|ijilipd; very irjii|p]»roprintcly, Wcnnso nppiin'nlly iiifornng that tho 
liiaordcr was of the nalnit of irritation, or neuralgic, not structural 
and inflammatory. It may occur at any age; and very frequeJilly itH 
origin is cooiiecltd with external iiijiirv- ^^ "^ ^^^^ ^^^^ ^^^ m^M^i. 
prominent pymi>toni!> is waetitjg of the dcltnid ; ultimately ;iivinflf a pro- 
iniuL'nci; to the ttcroiutun. Tliu nrui Is incapiililf orcxt-Tiiini ; aihl jmin 
in the joint is increased by moliim, csiicjially when llic nrui ib miHid. 
Bending tAkcs place iit the cllmw ; and llic limb priyccta awki^aidly 
from the liody, fteblo and wastcil, and apparently increased in lengtli. 
The siLouldcr simnlatea Inxution. And, at length, thi^ rcRult may 
iictnally wenr; ilisorganization of the Joint having becoDio uoinjik'te. 
The funslitnlitJii Joea not fail to snffcjj in sympathy with tinj piogrebs 
of this grave cJiHordt-r, Swelling'-, as nsnal iti primary nffcctiona of the 
hard tissues, in of w^cundary occurrence, and is Kidiloni very great; 
evacualion, by external ojiening', being soon attained hy Nature's own 
efibtt. 

Treatment ia to lie conducted on general principles. But, tme 
caries having been eslnbli&hed, >vilh an open comlllion of the joint, il 
liecomes very improbaUo that GpunLaiipoU!^ cine will tulic plnce j and 
usually the general ht-allh is ihcn wriously and (divionnly on liit* 
decline. In such circumstances, tbe ii[seased parts must Iw removed 
hy operation ; by acipiitafion nf the limb, or by resiectiun of the joint. 
The latter operaiion js obTionsly preferable, wben not expressly contra' 
indicated. 

RcMfcilon of the S/iftiiideT'JoinL 
To expose thp articnialion, a flap may be mnde from the outer and 



HGSECTRtM 0¥ THE BLUOW-JOINT. 



271 



fore-part of (he deltoid; or a single incisinn may bo placet! longitudi- 
nall/r o'^*>i' the miter aspect oF tlie j<.'Jnt, the linifo Ijeing entered below 
the acromion, luid piiEhed at once down to tbo head of tho humemft. 
In many oases the iMller lEodo U quite sufficient ; and, being less 
severe, is to be preferred. The knife and finger biiving penetrated tbe 
joint, the remaining portions of tbe retainiujj a]"p»r-itua are divided — 
more especially the muscles inserieJ ioto tbe tuberoHitles of tbe btimomsj 
towards wbi£!h the finger is the best s^^.- 

guide — and the dineaaed head is then 
made to shew itself, and project 
tbrongh the wound ; the limb bein^ 
with ibis vicvr brought forcibly 
across the thorax. l!y a ?4iw, ubbre- 
viatio[i Jft made in Mil- ivrjiiirwl ex- 
tent. The glenoid cjivity is thcQ 
examined ; and, if found diaeaserl, 
the uffi/cted part is taken away, by 
mcnns of cross-ouiting plieif, or by 
a gouge. Bleeding having been 
arrested, tho parlfi are ae*?urH.fo!y 
reponed; the wound is brought to- 
gether, and tho limb is rctaineil 
steadily in a convenient poaturp. ^'8- ^■ 

Healing by 5rannUti<in is to be expected ; wilh the formation of an 
artificial juixiL, more or less competent to assume iho functions of the 
'irijfimd. Often it proves in all rOH^ieetH an admirable t;ulistitiiff?. 
And thus many ntefiil limbs may bo retained, under circnmstanccK 
whieb, but a few years uince, would have called for nothing abort of 
amputation- 

The operation may also be required, primarily, on account of injury 
done to the bunu ; an by giin^hot wound. 





liesftclton of th^ Elbtnc -Joint. 

Few affection?! are more common than articular dise.-vae at the 
elbow. And not unfrequently il aiivances ti- disorganisation; with or 
without struniijua eompliuation. To this joint, more than any other, 
the ojJcriitioD of resettion xa applicable ; caru being nlitayfi tftken to 
select the case according to tbe ordinury le^s ; IfKt, rea^'Ction failinj^, 
ampidiition bcLoiiie necessary, and we discover, when too late, tbnt 
the patieut who conld have stond one operation well, must inevitably 
sink under both. The patient hflving been placed prone i>n a table, 
or seated wilh bis back to the Burgeon^ and wiih the iirm extended and 
held by an ueeietant, the jiMnl ia expoaed fr<^m behind, by ciitting, ho 



Fi^. W. Flap, placed hi poaittnn. after rcBCcdun of ibe ■'Inuldtr-joInL 



4 



272 



RESECTION OF THE ELBOW JOIKT, 



as to form flaps ; and the Hap may bo Gingle, dnulile, or quadrujilc ; 



or [hua 



The fi^re of the letter H 



In freeing Ihe soft pwtii from llie inner Liindyle, luid reflecting ihem 
over itf caro is nccoBBory to koop the ulnar norvo 64Lfo< The 




Fig. 100 



insertion of tha triceps having' Li*en cut acrosg, on bending the ann 
the olecranfin ia muilo pr<jimiieDl ; and this, having been separated 
from its conncsion with the soft parts, ii* romoTcd by saw or pliers, to 
tbe ref[uiaite extent. The joint can now he very readily dislocated ; 
the condyles of the humerna aro isolated and sawn off; and tlie upper 
part of the mdius, nanallyj is also removed — the saw heing preferred, 
to avoid hmising of tlie Btiftentd Ijone. Komnval of the olecninon by 
plicre iK mainly to futilitatu di«Lrticnlation ; afterwards it is usnally ne- 
oosBory to ^w Ehw^y so mncb DiurQ of the nlna as may i^eem bopcleealy 
dinGiiKed. Shoidd any auspicious portions appv/tr ai of near tlio cnt 
surfaces, the gonge rnay be directed against tliem. Bleeding having 

Tig. 1CN>- Indbion marked for reaectiim of the elbow, on the rii^Jit Arm. 



RESECTION OF THE VTRiaT, 



273 



boon arreste<i, :tnd the wpiind broa^bt ItHisely togetlor, tte liroh U «- 
omwl in a slightly Jifnt pfistitrw. Suppuration 
aod granulation follow ; the wound slowly 
closes; and an artificiiil joint bj ligamentona 
structure is ultimately conflLructed — often of re- 
markable usefulness. 

RpjecHon of the WriaU 

It were easy enough to remove by operation 
the articulating ends of the radius and ulna, anil 
to gouge out llie aBected parts of the corren- 
jjoiiding flurfucos of the caipal bonoB^ hot tha 
pruceeiling is xmt found to suci'eed. Ami, cxtw- 
wquentlji when this joint U deemed irrcd aim able, 
amputation ia preferred. Fortunately, a vast 
proportion of tlie <*ases of scrofuhius disease of tLis joint, in ndules- 
ccniSf re<joVfcr under uhj of foil-liver oil, and general antiBtrumons 
treatment — witL or without ancliylosis. 

Horeaiit ResecUnn dca ArtJc^ulotJoas, Jki:., Paria, ISOS. Rou, de la ScBectlon du 
Parlion^ iViJe, ^-2., PaHfl. 1813. Crampitni], Dub, IZoap. Itt^pnrtiit vol, W. 18^7. Vclponu, 
F^Duv. Elem. de Mml. 0]>erHtor, torn, i. Symp oa Ejtcidiou of JoiQU, RiUa. 1S31. 




\:\. 114, 



Fig. 101' CoHeB of Lfafl elbow; mainly iffeoEing the f'Ordyle of tbe hiunenuL Tb« 



J 



274 



CHAPTER XXIIL 
INJURIES OF THE SUPERIOR EXTUEMITY. 

Fracture of the Ciavicle 

TtiG clavicle U frci^ucDtly broken \ and iiBiially hy VLolebce applied to 
the at^romial o\fremity, as by falls on tie eWildcr The fracture i* 
generally oblique, and near the centre of the bime. The limb ih 
powerless, tbc pirL is puineJ and swollen^ attemptwl movement ag^^- 
vate3 the pain, uiul ibi.' f^hoiildcr is both Eunk and drawn towards the 
atemum. Displacement is t:aiir^d by depresHion uf th« lower frag- 
ment ; whereby the sternal portion is made very prominent, cauaiag 
palpable defurniity, and seeming to be ont uf place, though truly 
romaininp nearly in sit^t — the ftclion of the i>ectoral and stenio- 
niiistoid wusoles uearly neutralizing each other, and the bone being 
also atea<lied by tl»e coslo- clavicular lig'aiuenl- Tho acromial por- 
tion is <lragi;eJ downwardpi by tbe weight uf the arm ; and forwards 
and icwanls by tlit action of the aubcluviua — the altachmeiit of this 
mTwel*- to the first rib liein^ then the fixed point. 

The indications of treatment are [dain, but unfortunately not very 
eahily fnltilled. They are to raise the acromial portion to the eame 
level witli the tnternal ; to retain it there ; and ut the same time to 
keep the shoulder removed from tho sternuniT bo aa to prevent dia- 
plftctment icwards, and toneeijuent ** riding" of the ends of the boue- 
Many and complicjited arc Iho means devised for this end. The aira- 
plest, moat easily obtuincti, and not the least efficient, are as follows: 
A wedgc-ehapcd pad ia plaecd in the asilla, fiufllcieiitly large to 
occupy that cavity completely. The best pad is made of horsc-hiut, 
covered with Jiofl Icatlier; biil any temporary nubBlitute may lie tidiea 
at tho 6ral drtfciiiiig, iiy meaua of a nhawl or large haudkcrchicll 
within whieh it is iilaced, the p&d is securely lodged in the axilla; and, 
Ijy tying the ends over tho ojtposite shoulder Lightly, elevation of the 
flhoulder, and const ijueutly of the acromial portion of the clavicle, lb 
etfecteil ; and the latter indication is fnrlber contributed to, by placing 
the fore-arm in a short filing, well tightened over the elbow. To 
tuaiutoitj extonpion uf the bun*5 is moro difficult. Carry a baiidagpe. 



^ 



FBACTURE OF THE BODT OF THE SGAFDLA- 



275 



liandkerebiof, or otbor ligature, across the clieat — mcluding tbe lower 
part, nf Ihi* ami on the injured skk — nrrflnging it so Uiat thfi arm 
T^hail be kith approxiraaled to the cheat, and carried well backw^Lrds; 




Fig, 109 



making tlip hnraonis a lever, whicb, anting on t}ie pad aa a fnlonim, 
forces the shonlder outwards. And, if need be, niaintain approxima- 
tion of Ixitli scapulie by ineanB oi a figure of 8 bandage, so aa to com- 
pletc and Bccure the re-a^ljiiBtmeni. It h well alsn to relas Ibe stenni- 
masloid by allention to the po^niiion of Ibe ncek ; for Homctimea tbrs 
muscle would aecm to succeed in elcvnting the ulemftl portion nliglitly. 
Releution will to luoro esisily efTecLed in tin* ^rect or Bemi-orect than 
in the rocumbeuL ]X)sture. The knot over the fihoulder may gall the 
patient; and, to prevent this, the flkin shouM be well protected by 
Bnitable padding. The application of pressure over llie site of fracture 
can be prwhictive only of evil. The iulogiimenla miy l>e induced to 
sWgh ; and an injury, origioally aioplc, may be rendered coniponnd. 
In fenialoH, for ubvioua rcnBOnST the treatment is to bfl condncted witb 
especial care- 

Fraetiire of the Dod^ of the SmpuJa. 

The body of the scapula mny bo broken across, by violence 
directly applied, or even by rausonlar foree alone. There is but 
little displacement, or defi.Ttraity. The part Ih pained, swollen, and 
limited in voluntary motion; and, while movement is made, crepitus 
can be distinctly felt by the hand placed flatly on the part. In treat- 
ment, it In fiiinicient to resiruin motion, by wearing the ann in a 
eltng, and by having a brond flanucl bandfl§o pnseed tightly over the 
chest, including tbr frjLcJurei! bono. 

Fig. 102. Siaipla handiiglng auitnbb for fVicInred cUivi^'lp. The albig aniUt«d. 



276 FRACTDUE OF TUE NECK OF THE SCAPULA- 



Fracture of the Acromion. 

Tha acromiun process ma^ bo detached Troni Llie epine of the 
Roipiila, by direct violence. Tliere are pairii swolling^ and Iom 
of power; nnd a depressioii can be ftlt at tiie injured pnrt, in conse- 
quence of the fractured portion l>eing drawn downwards on the head 
of the humenis, by Ihe action of the deltoid muscle. At the aame 
time, the clavicle is drawn downwards and forwards on tlie coracoid 
proce&ft, hy the suhcleviiiRT nud bj tfco action of the dcUoid and pec- 
toralis major mufielee overcoming that of the trapezina and filerno- 
cleido-mihitoid- Crepitus is not felt oa rotating the limb, luitil the arm 
has been raiwd ; for tlien *inly can the fractured portions be brought 
into appfisilion. In treatment, it is suffieicnt to raise the arm fully hy 
means of a sling, ami to prevent motion by suitable bandaging to the 
tnmk. No ptnl ehoidd be placed in the axilla ; otherffiae the hiatus 
between tho frjictured portiotiE will probably he increafied. Union is 
generally by ligament. 

Fracture of the Coracoid Process. 

This injury is also the lesult of direct violetioe. The fractured 
portion is displaced downwards, by the action of the coraco-brochialie, 
peetoralia minor, and biceps mnscles. There are pain and swel'ing of 
the pari, with loss of power in the limb; and crepitalion is felt on 
rotating tlie limb, after the fore-arm has been flexed and the arm 
carried aerosA Ibe cliejit, in order to relax the muscles connected with 
the process, and s-i to permit replacement of the fraj,^ment. Tn treat- 
ment, it ia Bi^fGcic-nt to malte thia relaxation pcriuanent. The fingers 
of (he injiirpd lii»h are made to (oueh the shoulder of the opp<.«ite aide, 
and that poc^ition ia s\:curcd by bandaging. 

Fi^fieture of the Neek of Ihe Scapula. 

Thia accident— Bq>n ration of the glenoid cavity and coracoid pnK 
eees from the iKKly of the Ivine — ih the result of great and direct 
violence, antl^ like the preceding-, is of rare occurrence, SomelimeB 
there is mere separation of the ah<we ramed parts ; more frequently, 
the glenoid cavity is fissured and broken up. The detacbcii porlion of 
the Boapida is retaineil in close contact with the head of the hutnenia, 
by the iuiig hea<la of the biceps Jiad Iricepa mnscl^a ; uml both the 
fragment and the head of the humtraa are disploced downwards and 
forwards into the Bxilla, by the action of the siibscapularis and peetor- 
alia major, and of the other muscles cotincctcti with the ujijier part nf 
the humerus. The appearances are very like thow? of diab)ca[ion ; 
there is the same flatleniiig of the shoulder, with palpalJe prominence 
of the acromion, and vacancy beneath it ^ and the head cf the bone 



FnAOTORB OF THE NECK OF TUB UUMEltUfl, 277 

may be felt plaialy in the axilla ; at first^ too, thew i« no cTepitalinn ; 
anil the limL is eomowlial leuglhened. Bat, by very gentle effort, the 
head of tlie Wie may be replaced — a tliiiig very unusual, if not actiidly 
impracticable, in dislocation. Then crepitus rony be plainly felt, on 
rotating the arm \s'iLh one hand, while wiib the fingers and thumb of 
the otlier presinire la made d<jep in the oiilla and on thu comeoid pro- 
CGHS; then too, flattening of the i^botilder \s mude to disappear; bill, 
im ceasing froui manipulalioc, deformity and displaceinent are K|>eedily 
reprodnccd. In Irealment, a pad having^ been |»iaced in the axilla, the 
shoulder is raised and the fore-arm Eujiported by a sling'. 

Fracture of the Neck of the Ilwiierus. 

1, Fracture at the Anatmitkal Nech. — Occflsionally the bone givee 
way at this pninl» but not su frequently afi helow Uie tubercles. The 
injury is the reanlt of liirect violence; and inlracapsular. Tbere is 
but little displacemt'nt nr deformity ; the lower fra^ent beinn; n?tttined 
in ila ordinarv [xisilion by the miJsdcH iiiherteJ into the luberdes. The 
tfliicf tigiu^ arc pain, impmrmcnl of tnulion, and ciL-pitus. SuniclimeH 
impaotion tatos plfli^p^ the up[)er fragment bpini,'' driven into tlie cancel- 
Inud tissue of the lower; tlien the sl^nB are tiiinsnally obscure ; but 
the circumstance is favourable to obsoous and speedy reunion. When 
there is no impaction, the detached head of ibe bone may become 
iiecrostd; and bi that event indanmLaLory dis^irgani^alkih iisay bo 
OKp(;ct(td, fur oxlnititun of tho BOtpic^trtim. TrcELtnicut of this form of 
injury cnusiata mainly in ^ircBcrving qniettide in the parts. 

2. Fracture, by Separaiion t^f ike Fpiphijst's.^-'lhis a,]so is the result 
of dircL't violence. Tlie head of tlie lone remains iu its place ; while 
the slmfl is cirried forwanls ou the coracoid process, by the action of 
the muscles inserted into Ibe bicipital lidgea. There id litlle or no 
flatlening- of the sboiilJor ; llie head of the bone can be felt in situ, 
moti(>nlc?sfi on rotalion; the end of th« nhnft — directeil obliquely 
upwards and inwards — is felt ami seen projeilins on the coracoid 
proce&s; the arm ia Kbortened^ uich ibe elbow awkwardly projecting 
fron» the side; by aligbt extension ami coaptation adjuatment is readiiy 
effected, and then crepitus is emilied on rolatiun. The most charac- 
t<jristic Eig'u is the remarkabla prominence over the coracoid^ produced 
by the rcMiiig of the end of the lower fra^nent there. 8ometimefl 
impaction, however, oecun< ; the lower frao;ment bein^ driven into the 
upper ; and this neceKsarily cbscurea tlie KigTis of injury. 

In treating this form of fracture, a pad is placed in the asilla; by 
iwo Hplints of pasteboard, wood, or leather, placed one on the outside* 
the other oa the inside of the limb, retention ia Bocured ; * the fore-arju 
ift anpjw^rtfd hy a filing; hut the ellhtw is left free and j>pndenl^ Werf 
pressure to 1k> uiwle nn the ell}ow, by idjuslment of the sling in thu 
' SiTTH^timBA tL? iuu^ruB] epLini may be di^peiiAnl with. 



278 



FRACTUKE OF THE NECK OF TBE HDMERITS, 



ordinary way, Jisplucemenl of the lower fragment would inevitaLly he 
reprodnced; wLltco;!, Tiyfullowing an ojip^eitc conree, & ccTtaiu degree 
of permanent extension is maiDtnined on the bnniems, which is of naa 
iij preserving ap[Kj±^llioa. 

3- Fracture of Uie larg^ Ti^rcU. — This je tba reeiilt of direct 
VLulenoe. The joint ie pretematurally broad; the aiiromion projects 
somewhat ; the ilelloid is slightly flattened ; the arm is powerless as 
to elevatioB ; and two hard ewelliDQ^a are to be felt — one internal to 
the coracoid process, the bead of the bone — the other lieneath the 
Acromion, the detached lubcrcle. Treatment is as in the previous 
ipjnryj wJth tho whole forc-arra eupporlcd. 

4. Fracture at the Stirfficat AVci". — This ia also the resnlt of direct 
violence. The upper fragment remains nearly in its place, moved 
slightly npwanls and outwnrds by the action of the muBcles inserted 
into the Inbercles. The upper end of the lower fragment, or fihait, b 
drawn upwards and close lo llie side by the niuscles inserted ijilo tbe 
bicipital ridges; while ita lower tnd, a( tbe elbow, is abduulei hy the 
action of ilie dellmd on its point of insertion. The ftppearances con- 
sequently are — no flattening of ihe shoulder, on tbe contrary rather ft 
fuluesa ; the head of the bone felt plainly m situ, motionless on rota- 
tion ; the upper end of tbe fragmental tshaft li'lt displaced on tbe aide, 
and a dcpresaion plainly f>erceivL*d at a corresponding point in the 
eitcmnl outline of tbe lirob ; the arm shortened and poverlesa ; the 
ellfow ahdueted : crepitufiT "'" rotation afti^r a^ljustment. In treatment, 
a full Bized wed^-shaped pad is placed in the axilla ; splints are 
applied along tbe limb, tlae outer one extending from the lop of the 
shoulder to the external condyle, the inner from tlie internal condyle 
to tbe axilla; I lie fore -arm is mipjiorted by el sling; ami again the 

clbovr 18 left free and [>endent. 

5. Fracture ipit/i /J w/orj7hbfj,— -Fracture at either neck may occur, 
Li) consequence of frt'eat and direct violence, and be accompanied with 
disbjcatiun of tiie head of ibo bone. Fortunntely, the combination is 
of exceeding rarity. The HymptomH are necessarily eomphcated. But 
the dia^oBlic mark is sufficiently plain ; Ihe bead of the bone is felt 
lodged in the axilla, not moving along with tbe shaft in rotaticm. On 
r(i-adJHEtroenl, tiK», oharaetenHtic crepitus mjiy \)o delected. Treatmoot 
ia difficult. An effort ia to be made, by direct manipulation, to reduce 
the head of the bono if possible — of course under chloroform ; and if 
this bo accomplished, then tbe t^ase, having been reduced to one of 
fracture, requires the ordinary retentive Ireatuiont after due coaptation. 
Or, failing in dlr<.t:t coaptation, the fracture may he reduced and 
arranged tightly ii^ ^^pliiita, Kt) tM to admit of reduction of ibc diwlooa- 
lion by extension being attempted in the orfbnary way, liiit, if the 
luxation remain, notwithstanding every warrantable effort to remove 
il, then it were well to adjust Ihe erid of the shaft into the 
glenoid cavity, and to retain il there for a time by splints. 



i 



FKACTUEE OF TOE SHAFT OF THE HUMERUS, 



279 



ftuJ a. pitd in ihe ftsilla. The broken end becomes rininded off, ftsatim- 
iag an arficuI^T c^baraeter and function ; and tbe ntw joint ie Ukelj 
to prove moi'e useful, than if reunion bad beeu eflectad upon the dis- 
placed &iLgnient in Uit^ axilla. 



Fracture o/t/ie Shaft of Hit Siiinei-fi3. 

1. Dutow tJu Bhipiiai Ridges, and above the Imertion ofOie Deltoids — 
Here Ibe position of the rragmenls ia tbe revorne of what results from 
w>lutioii of contiiiuiiy at the surgical netk of the bone- Tbe upper 
fm^ment \h drawii inwjLrdsi to tbe aide, by the nm^clca inn^rted into 
the bidpltfti ridges; while the lower ia displaced outwards aud np- 
wBfda by the iLctioa of tlie deltoid, cauaing' an ahnonnal prominence 
at ibU part of the arm — immediately above the iiisertioD of the musok 
— with an inclination of the elbow to tbe side. The (characteristic: 
signs are^ tbe prominence just spoken of, shortening of the limb, 
crepitus on odjiiataiBnt and rotation, and lulductJon of Ibf^ elbow< 
Coaptation having been uflbcted, splints un> applied, a pa^.i is arranged 
wj as to keep tbe upper fragment s«]iaratc from tbe cheut, the fore-arm 
is 8up[M>rted, and the whole is aleadieil and retained by suitable 
bfliniag-ing- 

2- At the Middle of thu Shaft. — At this point the nature of the 
injury in at once m,idc appan'nt, bj dtfunnilyT shortening, arid power- 
lessnoK!* of the limbj with distinct cropilns yniittt-d on the slightest 
manipulation. Reduction Ja easily eflVeted, by extenaon and coapta* 
lion ; and retention is maintained by spliots ; the fore-arm lieing also 
supported by a sling. 

3. Ai the Shoji above the Coitdi/les. — Here tbe solution of conti- 
nuity IB generally oblique ; tloylu^ down from behind forwaid/^. Ar*d 
the apiwaranncH simidate thoae of dislocation nf bolli bonra of the ft»re- 
arm backwHrlrf. Tbe lower frajjmtnt is drawn upwards and hackwHrda 
by the action of the biceps, triceps, aiid bracliialis auticus. The lunb 
IS shortened; and there \n much bulging |josleriorly. On extending 
tbe forc-ariD, passively, the deformity is removed ; but on resiunpLjon 
of the fle:ced poature, it is instantly reproduced ; and by tlm teat the 
accident is sufiiciontly distitignish<!d from dislooiition. Crc'pilu^ luay 
be plainly perceived, on eombining coaptation with rotation. When 
the line of fracturu follows an opixjsite direction, passing obliquely 
upwarda from behind forwards, the displacement iti reversed ; the 
lower end of the upper fragntent projecting behind, while the upper 
end of the lower iVagmeut \a drawn up>\ards iii fixint, Reduction 
having been effected, rectangular tqdinU are applied on tbo iriside find 
uutside of the limb, and are retained by bando^nng ; the nctanguiar 
j*oaition of tbe fore-ano being obviously advisable, in order to relas 
*be displacing muscles — the biceps, triceps, and bracbialiE antieus* 





280 FRACTCKE OF THE ULNA. 

The Biilirta — mnde of pastelward^ leather, or gfuHa-percba — shovM 
exteofl from near the miiWle of the ttnn quite lo the mist. 

Diastasis may occur ; wparalion of the epipLjeia, with or without 
rotaiioo. Reduction having been efiecleii, by exlenHon and c^wptation, 
rctcntioQ 'will be niaiataiucd beet in ibt: bent pobilitjn. 

Fracture at the Condyles oftlie Humerus. 

1. 0/fhe Infernal Condt/le.~'T]\G line of fracture is ohliqne to the 
ehaft, detaching tbe internal condyle. During flexion of iLe fore-ann 
there is little or no displacement ; but, on extension, the aina is drawn 
upwards and buck ward a, by tJic jLclion of the tricepB, there being no 
looger any efficient resistance to the coronoid proecGS, Tlie signs are 
— crepimB, on direct lalerfll movement of the injnred part; obvious 
<lisplaeenient of the ulna in extension, iind replacement of it by flexion 
of Ibe fore-arm. In Ireatnienl, Ibe timb is arranged in a retlangiilar 
liOKilion, as for fracture abi>ve llie condyles. But from liuie tp lime it 
i$ c^pcdfunt let nndo tbu oppar^tne, and pracliEio pabbivc movcmaut of 
Ihe joinl, lest »iliffi*ning ghoidd ocrnr. 

2, Oftfif External Con ;^j/^r.— There may he Utile or no displace- 
ment in any position of the limh. Kut crepitna is lo be fell ; mi're 
especially diiriug rotatory ni<»Yement of the hand and radiuB, Treat- 
ment U us in the preceding cuso. 

Fracivrt of the Ulna, 

1, Of the OlecTfinon. — Tliis niay bethe refiull of direct injury, by a 
fall on the elbow; or of niu&cnlar aclion only, in violent and sudden 
exTeiifiion of tlic Unib. Usually, ligiimeui us "ell as l>oi!e is torn; and, 
consequently, the olecranon, dttathc^d from tUe aliaft of the ulna, ia 
displaced upwards by th^ action of the triceps^ leaving a x'acant space 
where prominence should have been, and placing the promineoce an 
inch or more above its ordinary site, Vohniturv exIersioQ is imprac- 
ticable ; llpxion flggravaiee the signs of the injnry. On extending the 
limb, the displacement is in a great measTire removed ; the Iwo frag- 
ments are brijtight Biiirn;ieijlly ntnr for ialisfactory lig^amenion^ unioti ; 
and in troalment, therefore, it is enough to maintain ths extended 
position, by ibe looee ai^plicalion of a t~p!int on the palmar aspect of 
the elbuw-joint. Veiy accurate a[n>rosimalion, indeed, is not desir- 
able; a compact ligamentous bond of union beiiig equally Berviceatlo 
as an osseous one, and much less liable to a &H:ond disruption. Like- 
wise, the risk of eiceteivo osseous depoal is avoided, whereby the 
fragment might become inconveniently anchyloHjd, on its articulating 
aspect, with the end of the humerus. 

Compound fracture of the olecranon follows direct injury; and is 
invariably to be regarded as an accident of seriouB import; inasmuch 



rRACTURE OF TQB RADTtlH- 281 

ae iotetiHe inflammitiiin of tlie pint is very likely to enpervcne. And 
liiis lendL'iicY lo serious evil we aliould never lose Bight of, in trealraent ; 
endeavouring lo prevent traumatic arthritiH, if possible ; and "when it 
has cH^nrred, doing our uimaftt Co avert ditiorgatiizatian. Not iin&e- 
qiicntly, wiib tlie Lent care, the joint suppurfttcH, and ia with difficulty 
Bavf>d liy ant'hyloRif!. Romelimet; even ampiilation is d^nianded. 

2. Of the Corormid process, — This rare ac<,-ident is more likely to 
followinordiiiale muscular action than direct injury. The ulna is dis- 
placed backwards, by the unresisted action ef the tricopB ; and lUe 
tendon of the bceepa h rendered tense ami unuhoally proniincul by the 
bulging forwurdft of the Irochlea of the hnraerus. The coroooid frag- 
ment is drawn upwards hy the brachialis nnlicitB. Ia treatment, th« 
fore-arm iH placed in a state of extreme flexion, and i-etained so by ban- 
daging, Ski as to reljoE Ihc displacing bracldalls. Ligamentous union ia 
expecled, as in the case of tlie olecranon, 

3. Of tfie ^/idft.—Tli: weakest iHiiuL of the aliafl of the ulna ia a 
liitle beltjw ita cenire ; and there fraclnre la must likely lo ticetir, from 
violence applied indirectly. The lower fragment is drawn to the 
nuIiuFt, by the actiun ^f the proniilor (juadratus muscle; and conse- 
queotly a dcpreasion is ma^le there in the outline of the ItoneBr until 
obscured by sunguineons and inflannnutor>' swelling. There is neilher 
pronation nor supinaiiou of the hand. By coaptation and rotation 
crepitifa in reaiUly jierccired. Jn treatment, aphnts are applied on tbe 
palutar and dorsal oejjiocU ; E'acli t>']diiit pxtvnding frum the olbow to 
beyond the wriat, £o as cotnpletcly la comnijind Ihe laller articulation, 
Andj in order to prevent redisplacemenl hy the jironator qnadratiis, & 
pad is placed on either aKf>ect of the fractured part, of si;3ici^nt size to 
occupy ihe iiileroBseouft space fullyjand solo offer a mechanical obslacle 
to uijiJLic appro Ttinialiui^. 

4. Of the ^fi/ht'd pro^fst. — This process may bo chipped off, with- 
out other injury lo the Iwne. There is little iudicalion fur Ireatment 
beyond rest of the part until pain and swelling Lave uubhidcd. 

Fracture ofths Eadius. 

In tliip injury, it m convenient to ohser\'e» as an aid in diagnoaiii, 
that tliere is invariably abnormal pronation of the baud ; whether thu 
bone have [>nflered alone, or in ci^mpany with the ulua, 

1. At itf neck. — This is an uceiilent of ntre occurrence, and difficult 
diagnosis. The fragments are bul little displaced, and crepiius has to 
be detecied ihningli a thick cushion rf muscular subslajicc. The 
lower fragment is tilled forwards and iuwarda Elightly, by Iho action 
iif the bi<;L'ps ; the upper is rotated somewhat ontwards by the supinator 
radii bre^is. Crepitus is to be sought for by firm pressure over the 
site of suspected fracture, while free rotalion is made of the hand and 
fore-arm. In treatment, the fore-ann is flexed, and placed in the 



282 



FRACTURE OF THE RADIUS. 



middle atale between pronation and gapinatiou ; long splioia being 
applied on cither aspect of the litub. 

2. Near the Centre, — Tlie vttdius very commonly givea viv^y neur 
ita centre, from viok-ncc indirectly apjilied, os by falls on the bajui, ot 
by twisting of tlie fnre-arm. And sometimes Ibe aceident is Ihe rt*Riil| 
of mnscnlar action alone. The unnatural degree of pronatnjn ia yery 
marked and cbaracterislic, tbe band bunging awkwardly witb tlie 
thumb dirceted downwards. The upper fragment \^ drawn upwards 
and inwards, by the action of the biceps; and ihero is an apparent 
enlnrgcmtmt of iho upper half, witli a diminution of the lower btilf of 
the fore-arm. The lower portion of tbo frnotnred bone is drawn 
towards the ulna, iis well aa completely pronatod, by the action of the 
pronator qua^lratus. And the f^npinator radii longus assists powerfully, 
by tilting up the ntyluid process to which il is attached, in displace- 
ment towards the ulna. In treatment, tbe fore-arm ia flexed, anil 
placed in thi- middle btntc bi^tween pronjition mid supination ; the 
internsBeous paiLs aro eart?fnlly adjiisted ; ibe hmg Bphntfi are ujpjklied 
on eithur anpect, projet^linjT Iteyund the kuuctlL-s; the band, baiulajfed 
separately lo provent congestion, is escliideJ from tie retentive ap- 
paratus, and left pendent — so that by ita weif^bt it may counteraet the 
displacing tendency of tho lon^ Bupinalor, and sejiarale the mdiua from 
the ulna at the \ni\x\i of fracture^ 

3. At tfif Distal Er fremiti/.' — This, U\o, is a very common result of 
falls on the baud. Tlie rmliiis being uuiinly eoncprned in tbo carpal 
articuktion, lo Ibal bone tht; Bin)ek is chiefly and directly ci^nveyedj 
and Bfdution of conliniiily iv extreuiidy proliable, more especially if any 
degree of twisting have been at iIjo t^me time applied. The line of 
fracture may be fither tryii&verae or oblicpie, Tbe upper fntgrnent is 
Jiepbie^d iu\v'ai"dfi l*y tliu j)runator radii qiiadriitns ; oauaiug an abnor- 
nnil proniineiico on the palmar asiwct, with a corresponding deprcsslcm 
on the doraal. There is pronation ; aud^ cm eoaptution and extension, 
crepitus may bo delected. The hand, following displacement of ibe 
lower fragment of the ra<bna outwards, leaves tbe end of tbe ulna 
minauully protiiiiient— — as if dislot'attd. liiisalioii of the eurjuie, indeed, 
is ID not a ft-w eaees closely eimidated. Tbe dlagtiottie ijiarke arc- 
detection of f'repitua, mobility at the injured part, and in genernl non- 
continuity of the bone m evinced on rotation. But the c^ise becomes 
obscure when the lire of fracture is oblique, and impaction has occurred. 
Tho lower fragment having received Ihc Fhaqi end ol tlie iipj^er into 
\Xe caneullated tissue, the two beeoine locked, coiitiuuity of the lune ie 
appareatly restored, and crepitus ia felt but oliBcim^ly, if at alb AVhen 
in d<mbt, let free cstensdon be madi', sueh aa may Yindo Ibe ftlale of 
impacliim, and then, if fracture exist, its ordinary sifrns^^iU be evinced. 
in treatment, il is neccRSJiry to be very careful t o eftVcl ftcctira te co- 
aptation by reduction ; then to ap[d}- the lone: A^^^^^Bfor^al 




FltAQTURE OF BOTH EADIUS ANll in.NA. 



283 



Aiid palninr aapectB, fleeurin)? th<> wrist and h&nd against every motion. 
Tht' fore-arm is placeJ in tbe r^tile of e-isy flexioTi. 

Lately, it Lilb been ]jro[>ose<1 to treat tliin fruoture witlioirt eplintti. 
Tbo Land '^ having been bronglit into a position of strong llcxiou, the 
foro-ann it^ plaGi>il, prc^iiAt^d^ on an obltqne pkin^T with the caTpm 
highest, the hand beings i^rmitted to hang freely down the i>erpendi- 
vn\s.T end of the plane/'* 

Fracture ofhotfi Rfifiius and Uhio^ 

Thie i9 ordirnirily iho romilt of direct viulcnco ^ Jind tho fracliii'CB 
codfieiiuently are at corresporiding points — usnally near the middle of 
tbe fore-ann. By the action of tlie prunator quudratua t!ie hand in 
pronated, and the lower fragmeats are approximaled to each other; 
Ihey are also drawn upward by the corahinc"! tiction of the extensor 
and flexor musules In ttio fore-arm, and usually projeet on the dorsal 
aai«ct of tbo limb. On cxtcnBion and rotation, crepituH may bo very 
plainly jHTCPiveti, The treatraiint ie, aa for single fracture, by long 
splints and interossbons pads. 

In young ])ersonfl, both hones Dot unfre<iucntly give way at their 
fpipki/ftfs : an aoeirlpirt which closely simulates luxation of Lhe carpna* 
Like frauluru of the Tctdiua alone, it is usually tbu rtsnlt uf indirect 
violence, by a fall on iho liatid. The lowor friigiiii'nta, with the 
carpiiB, are ilisplaeed b^ickwapd-i; the upjHjr prnjt'ct on tht- palmar 
aspect. Thu latter are kept in close approsimatiim by the jirtinator 
qnadratus, while the fore-arm is pmnatcd by the pronator radii teres. 
Considerable power is reqnired, by estensien, to undo the locking^ and 
disjrlactiUH'nt ; and then erepiLui^ is cmitLed on rotation. Tbe hand 
osiially remains in the middle Estate bctwo^n pmnalion ami Bnpinatiou. 
In trcatnii?nf, coaplatiim, by efficient extension^ having l^een sL^com- 
plished, is maintained by lon^ splints, as in the other fractures. 



FracttJTe of the Metacarjtal Bonix. 

The Carpal bones aro eeldom fractured but by great and direct 
force I and then the frjtctnre is not only oompound, but also generally 
accompanied with mich injury to other parts as to call for amputation. 
The MHacarpal bones, however, not unfreqiiently give way — amply, 
and remediably — by force either <lir^;et or indirect; most frequently 
ihe latter — as in violent blowa delivered on the ktiuckles. The frag- 
[nentfi may bo made to ride, by the force which occjveioned Bolution 
of continuity ; ^md l:ttL>iid dinphiooinont may \iii T^nhst-qiEently rnnsed 
hy action of Ihc int(>roiJHeous inu&clcii. Tlie swelling, pain, and |>ower- 
Icsfiness of the llmbf with characteristiG ore^atiis on manipultition, are 
snflicienlly indicative of the nature of tbe injury. Coaptation is 





284 UIBLOCATIOS OF THE CLAViOLE. 

effected by extensionT and is secured aflerwttnls by splinla, esleiidiiig 
from above the wrist lu beyoDd the tips of the fingers, on either aspect, 
lutcTosfieouB ya/^a umy be arnrngcd on each side ot' the fractured hone, 
OD llie dorsal ospt^ct ^ od the palmnr, one Iaf^ and siiitjjble [>%d is 
pl&ced, t£i occupy and maintaiu tike hullow uf the iiHtnral axcb of the 
Land- 

In coDiiiound iojurieB of this part, amputntion is to be had recoiinse 
to with reluctance. When it is inevitable, let it be as partial and 
Unfiled as jwaaihle, for the obvIoiiB reasoiia formerly etrtteJ when 
treating of ampntation on account of disease. 

Fracture of the Phalanges, 

Fraottuos of Ibe phaUogca are nsually cocnponnJ, But, whether 
componnd or nimplef their mnrka are &o plaio ua 1u tender lui^Lake 
under uuy circnm stance a imiH>K6;iLle, ^Vht■n prcKervatiun of tile 
injured part i^ deemeil practicable and eipcdicnt^ rcdiiclion is cartfiilly 
effected; and coaptfitiim ifi mabtained by Blender B])iinLB of wood 
placed OQ the dorsal iind palmar uspects. 

DISLOCATIONS. 

Dislocation ofihe Clavicle^ 

1. The Sternal Extremiti/ may he displaced either backwards or 
forwards, a. Forieards. — Dislocaiiou forwards is by luneh the more 
frequent; produced by force appUt'd infJirectly, thr^iugh lie Hhcmlder- 
The dislodged eilreraity is seen and felt plainly resting in front of the 
bternnui. Replacement is effected liy rai^ng the shoulder, and by 
earrying it backwards si» as to approKlmate ibe scapulff, Trealmcul 
IB tho Bauic ua for fniclure of the bonp, excepting ihe pad in tlie axilla, 
which is here unneceiisary. b. Bacl:u'ai-d'i. — Dialucaiion biickw'arda la 
enlremcly rare. It hus rcsnlied from din^ct violence applied lo the 
p^irt, nn<\ also Irom llie gradual displaeement which allends on rotation 
and curvnlure uf the spinal cohimn. To effect reduction, let an itssis- 
tant gra^ bolh ehoulders, and, placing his knee between, Middenly 
bend them backwards lowjirds each other ; while the surgeon in front 
pnllB forward ihe end r»f the bono. For reteiilion it is neccssiiry to 
remove the shoulder irain the eidr ; and this may be dene by placing 
a large pad in the axilla, and binding down the longer end of the 
humenis. In an exanitde dependent on spinal curvulnre, it was found 
impossible \o retain the end of the bone in iis proper place ; and the 
distress occasioned by its back^^'ard preeenre proved to great as to le^d 
1o extirpation of tiie ofieading part.* 

■ X. CfX»PEn on Dblcq:aIio»?, Imi edition, p. SM. 



1 



-^*<=^v. 



'-^o^ 



284 



liMlflMTiflH"'^'^"" "'""'•"■• 




DISPLACEMENT OF THE AN3LE OP THE fiCAPULA, 285 

2. The Scapnlar Ejjtrcint'tif is not iinfrequenU/ dieplaced ujiwnrda 
on th*? acromion, by falls on iho shoulder; the araoimt of deformity 
&nti incoQvenietice being proportion eil to tbe degree of lacerfltion (tf 
tliG coTifi[Lin<^ {igamcnts. The ehoiilder is deprcEsed; and the end ol' 
thfl clavicle is ween and felt rising over the aj)iae of tbe EciipuU. 
tteducti'm is effected by elevation and retraction of the shoulder ; cod- 
tiequeiilly the same treatment is necebeury as for frdtiured clavicle; 
but mAiiitAincd with unneun] ai^urooy, as well as for an uniiBual leuglh 
of time — ihc bone being vory liable to re- displace men*, and consoli- 
dation of tbe ]iganientons apjjaratna being apt to prove both tardy 
and imperfet't. 

Displacement of the Angle of the Scapula. 

Young men, who ueg the arms violoully in thtdr habitual occiipa- 
tiooH, are li^ible bi this nccidenl. The bitissiraua dorsi paRSea beneath 
inatead of nvcr the lower angle of the scapnla, causing ui]6<?emly pro- 
jection of lliis, with pain and loss of fimrtion in the limb. Ri?duiition 
i>t enwily eflecleil liy direct manipulation, while the arm is much niiscd 
and hiMMghi bflckwarls, bo as to relax the muacle; and by bandaging 
and reat the normal rthition may he mttinJaincdH On resuming the 
use of the arm r*?'d is placement is very apt lo occur; a circumstance 
of the less moment, however, as in time both power and extent of 
motion are nlmost completely regmncd, i ii depend cutly of reilnctlon. 

A more ?>erioua deformity is connected vrith paralysis of the rhom- 
boid tniificles, and occurs in young persons who follow confilrained aud 

Hcdciitai-y HVocfttioQH, Dij?pla cement of tlje losvcr angle not only takcB 
place; hntj behide*<, the hnsR of the bono projects forivaTtl'', on moving 
the sltmilder, to each an extent as almost to admit of the hand being 
placed between the subscapularis imd the ribs. In ibis ease, treatment 
must be mainly constitulional ; but the attention is also directed 
towards resloration of tone iu the faulty muacluft, by galvanism, fric- 
tion, and other mcanB. 

DUlocation of the Humerui at the Shoulder. 

This is more likely to follow indirect tiao direct violence. There 
are varieties ; ihree complete luxationB, and two partial diBplaceraents. 

1. D'fsiifcatton (loxciturards^ into the a^ilta, is the moat common- — 
indeed is regaided as tbe ordinary form of injury. In addition to tbe 
general signs of dislocation, there are the following: — Tbe shoulder 
is flattened, the deltoid having sunk inwards; an ample and evident 
space eiista beneath the acromion, which process is unusually and 
strikingly prominent; the arm is slighllj elongated; tbe elbow is 
abdui^ted from the bide; on eltjv«ting tbo limb, tbe head of the bojio 
[8 plainly felt iu the asilla — and it i^ found to move with the fih&fl in 
rotation ; motion is greatly abridged, unless when the muscular system 




DISLUOATTON OF THE SHOULUES- 



IB unusually relaxed and flabby ; there is no tine cre[rtUm ; pressure of 
tbe borie'H bead on nerves and veins in Ihc axilla is evinced, by 
tingling HenBations and awolling of the hnib; paralysis may follow; 




n^. 101 

not unfreqneutly tho circumfloi nerve lias been tori] aeroB*^ and per- 
manent paralvHia of tbe deltoid has resulted. 

Reducffon may Ijg effected, ia a variety nf ways; pnllcys being 
used, or not, according to circumstances. In all cases of difliculfj, 
chloroform is of conrse employed, o. By TCcUzTiqulnr t'^rt'-nsmi — tbe 
axis of ex-tensiuii Ix^ing inti^nded io rc-lflx the dulloiJ, biipni'spinatus, 
and itifrn-BpinatiiB ronBcleB, which, according to Sir A. Cooper, urc the 
prncipal op|)onenls of reduction. Af>d it ia well to relax Ibe hiceps, 
also, by flexion of tlie foTc-arm ; tbe laque being attache*!, when 
required, above tbe elbow. Tbe patient may be cither seated or 
recumbent ; and conntcr-estensioa ia made by a brnad sheet or belt 
piLSBC'l round llic cbett — pressure being at (lie eamo liiiie uiude on the 
top of tlio shoiddor, bo oa to fis Iho scftpiila moro complotelyi After 
extcHsion has been duly sustained, it is auddcidy slacked, and a jerk- 
ing, coivptating movement is made oa tlie head of tbe bono upwards; 
the humeruF bring uwd aa a lever. When tbo patient is seated on a 
chair, much ^jo^s'er in this way is obbiined by the knee placed in the 
axillji, on which the hnmerua is, as il were, fiiiddciilj and forcibly 
bent. Redaction may tikko place tuddouly, and vilh a snap ^ or gra- 
dually, and withoet a noiso. Then the nrra is secured to llie side, by 
bandag^ngT ^^id retaineil so for a few days. 

6, Bj/ extejision paralld la the axin of the body. — Thus we may 
succeed, Bingle-handed, iu recent or otherwise favanrable cases. The 
patient is laid recumbent; and the BUrgeon places bjmself, sitting, by 
his fiidc. Taking hold of the hand or wrist of the injured limb, ths 
mirgeim makes eTteuBion by pulling towarrls bini- while, placing hia 
nnbooted bed in tbe axilla, on the head of the hone, and pushing from 

Ft^. 103l DLAldcAtion of the ^botLlilcr. Th^ flatttmng Ahewnat n. I'he ri^lit rtbuulder 
!■ hottilaI. 




DISLOCATION OF THE SHOliLDEB. 

Lim, conn t«r-Gx teas] on is marlt, and at \\iG same time direcL redactivo 
force IB appliej. Or, iiistcud uf luillii^^' by llie wrist, a laqiie may be 
fastened alovc the gWwv ; by a ^Irap or lowel altauhed to wiiicb, and 
paased iKjbiud tbe mirgeon's back, esienmon may be made ; leaving 
tke batiHu free to Totatc the flexed faro-arm. Cure miist b? taken, 
bowever, llial tbe betl's fierce is neither cscesaive^ nor unduly directed ; 
for it baa buppened tbnt, failing to reduce b dislocated hum^rns, tbe 
operator bas canned fracture of tbe ribe. Riipturo of the axillary 
artery, also, with siibsoquent forDjatioa of false aneurisDi, baa been 
cauaed by ibe bctl — buoled, and used tasbly. Failing wilb tlie heel, 
the Etrap for producing cDHntvr-extension is placed in tho axillo, and 
eitcnsiou made steadily witb polleys, witb sucb rotation and manipu- 
lation as seem necessary. 

c. By movemtnl upwards. — Tbia is ibe method of Malgaig-oe. Tbe 
shonlder and cbeet arc Bteadied, while the urm is forcibly raided above 
the head; and, if need be, eixJenaioo is maile in that dlrtction, witb 
flubaequent m&nipnlatioa directed against tbe bt^od of tbe bono. It is 
expected, however, that these lallcr prticeedinga may not be required, 
tbe bone slipping into its pbico diiring the upward movemeot. 

Such details as to reduction apply mainly to those causes, iu wbicb 
from some cause or other auffslbosia ie not em})loyed. With tbe fidl 
effect of chloroform tbe muecular framt; is fuj rcln^t^d, that in ^neral 
little cho than Biiaple estenfiion, witb coaptation, is ri?qnirod ; it being 
comparatively immateiial in what direi^tion the extension is ciado. 

2- DtsfoCiUi'in fijru^ards, beneath t/it pecC*>ral nmscle. — The bead of 
the bono is displaced to the inside of tbe coracoid process, and ts 
locked between that and the clavicle. There is the same flattening of 
the bboulder, with abnormal subacromial apace, jis In iXm picLfding 
accident; but to a gre.iter extent. There is lesH pain, the axillary 
plexus beinff free. Motion is more abridged. Tbe elbow is abducted 
and thrown buck, Tbe bead of tbe bone may be both seea and felt in 
its abuurmal site. The arm ia somewhat s1iorten«:d. In reduction, tbe 
extending force is to be made downwardj^ and backwards, in a line 
with the boily, not in n rectangular direction; in order Eo iivoid the 
resietnnce i>r the coracoid process. 

3. Bacfcivards on the dorsum of the seapula. — This is the rarest 
form of complete luxation. Palpable prest.^nco of the head of the Ume, 
in its new locality, is snfGciently djjignostic. Ecdnction may htj 
effected vtry aimply, by merely elevating Uu^ arm, and carrying the 
hand behind the bead. Failing this tbe ordinary meana are to be 
employtid, as for disloeation downwarde- 

i. iiultluxativn on the coracoid process. — A parlin.1 displacement 
may take place in this direction. There ia slight flatteninf; of the 
shoulder, witb a corrL^si>oiidijig degree of vacancy beneath the acromion; 
and the head of tbo bone is felt and seen projecting on the coracoid 
proceesH Reduction is beset with no diOiculty ] in fact the manipulation 




2ftS 



CISLOCATION OP TEE ELBOW, 



required fur diagnosis generally Butceed§ in effecting replacement. The 
accident is rare. 

5^ Sub Jitxft lion upwards, ti*tfh diipUiceinent of the long htad of the 
hkepi. — TLe long tendon of thia mugole may be difiplAced from tlie 
Incipital groove, and laid over the lesser tnl>ercle. In consequence, 
the head of the hnmerns escfipes upwards, coming into in^mi-dlale cod- 
tact with the acromion. The 4iccidcnt is oLflcnrCt and probably rare* 
II IS not<;d by loss of jiower in the bice^Ts, by pain in [he seal of injury, 
and by the pecnliar defcu-mity attendant on the npwaivl displacement 
of the head of the b*>De. Redaction is effected by a conptjitin^ mani- 
pnlatioDf directed to the tendon, during flesioo of iht: fore-aruL 




Dislocation oftia Radius trnd Ulna ot iht Elbow. 

1, BarhDardt. — Both boncB nf the fore-arm are not nnfreqnently 

displaced backwards, wilhont 
fracture of any part, by Callft 
on the hand, with the etbow 
in a state of te mi flexion* 
The! joint ia much deformed, 
and had its motion greatly 
abridged. The 
^^K-^"' hand and fore- 

arm are supine; the joint ta bent Dearly at a right 
angle^ and can be neither completely flexed nor 
extended. The ulna and radius form a very marked 
projeotion posteriorly- and, on exftminatlon, the olecra- 
non is found on a higher level than the external condyle 
of Uie hnmenis. The coronoid process uf the ulna 
i"e8ts in the cavity which ought to receive the olecra- 
non ; and on each side of the olecranon a hollow Is 
canbt?d, by absence of the lower part of the triceps 
from its wonted locality. The trochlea of the humerua 
prujectJDg forwards, forma a hard swelling behind the 
tendon of the bice[>9. 

licdtiction may be effected in t^vo ways. a. Bj^ 
extetiiiem, loith coaptation, Jrom behind. This is the 
prefurablQ mode. The patient is placed with bia back 
to the surgeon ; and, the chesl leaving been fiscal, 
extension is made witli the anu directed completely 
backwanlH, in a rectanpilar relation to the trunk, so 
aa to rchix the Iricejts muscle. Very frequently, in 
recent caaea, the operator llnis succeeds, Binglo-hauded, 
by •xtoamon alone. With the left hand he makefi 'ii»i«" 

wHmtor-extonaion on the acapnia, while with the light he e^ttende from 

Tit;. ^^" DL-*lDC4iOj.m uf tmlb Ixpiitt Imcknanls. 
VUt- IMh Dinloc-ition of Ibii elbow; ibewing prrtaniBCural f^lneai in ffrtnl. 



r 

i 



DISLOCATION OF TDK OLNA. 289 

tlie wrist. In difficult cas^fl, ext^asioii is iiitrufiteiJ to asdetftnls, ^ith 
or without puUejttj while the surgeon conducts the direct coaplating 
maaipulations of the joint — the patieDt unJer chlorofonn. h, Btf 
forc'tbhf bending ihi j\>aii over iht knes^ — Tiie patient having heen 
Heated on a <:hdr, the surgeon places hia knrc in the boHow of the 
elbow. Pressing the rwliua u.nd ulnn tlown upuu the knce» the coronoid 
proceBfl IE freed friim the bumeriis, by tepiitation; and then, on forcible 
yet gradual flexioiij re<1uction is effected. 

2. Laterallr/. — Bulh hones may he disi)laced laterally, as well 
as backwards, in twti ways ; to the inside or to the outsids'. a. Back* 
wards and ouhrards. — Tho coTonoid precofs repU on the hack pari 
uf thy fjjitcni^l ci^mlylL-. The ubia pTi>ji;cla uiure bm■k^^Jl^d.'^ Ihan in 
iho ordinary diKlocotion. The rndius forms a protuhtranoo hohind 
and on the outer side of the elbow, wliere its head may be fult plainly 
rotating. The inner condyle projects palpably, b. Bca:f:ioards and 
inwards. — Tfie external condyle projects. The ulna ih prominent 
poHicriorly, restuig ou the inner condylCj while llie head of the radiuB 
is placed in ihc poslciitir foMa of the humerus. liediiclitm^ in eillier 
•iOAVj irmy be offoclod as in ordinary dislocation. 

Dislocation of th^ Ulna at the Elbow. 

The ulna may he dia^ihu^cdj singlyj in two directions, 1. Bark- 
wants. — The olecTanon prujccts beLiiid, The fort'-arm is much 
Iwifltt-d inwjirdw, with proiintiou of the hand. The clhow is bonl 
nearly at n^'bl ani^leri, flexion can he bnl vcrj' alighlly increased, and 
extension is quite im practicable. Rt'dactinn is ell'ucted by bending; the 
elbow over the knee, and drawing the fure-ann downwards. The 
radioB proi'es of use, in thia raovemenlj by pushing the external con- 
dyli; back iqmn [\iv uliiii. 

2. Bachi^ards artd inward^-' — The olocrauon projects much liehind, 
the coronoid proopps jv.rU on the inner condyU, and a finger may be 
placed in the siginuid cavity. Tlie Afre-arm i» Etmidext'dT the hand 
pronated. Extension may be pertormed readily by tlie enrgecur btit 
complete flexiitn U impractieabie. MulIi pain is experienced, on 
account ot pn^ssnre on the ulnar ner\'y, Heduction is (JVeclcd by direct 
efforts of coapliitionT during powerful and eustuincd i-xtcnaion. The 
accident in rare. 

Di slot fit 10 It of the lindiiis at the Efhow. 

The radius may he displaced, singly, also in two direcliona. 1. 
Forwards. — The bead of the bone rcBla in the hullow above the 
external con-lylp, sind may ho felt there. The foro-arm ih RlJghtly 
bent, and can bo neither cornplelely flexed nor extended. On attempt- 
ing fleiion, the head of the radius is felt to strike against the humerus, 

u 





DI6L0CAT10K OP THE WiUST. 



Al>mptly arresting the moveTnent. The baod is incliDed to pronation- 

Jiedticlwn is efiected Uy grospiug the 
Land firmly, iierforming Bupinatiim, and 
extending tlio fore-arm elciulily. 

2. Baeht'ards.-^ThQ hpad of iha 
raUiiis is displaced behind the external 
cocdylsj and to its outside ; and \n this 
locality it can be botb seen and felt 
very plainly, especially on extending 
the limb. Medtiction is maii&ged oa in 
ihe preceding accident; bill with the 
t'ig.iGfl. baud pronated, not enpine. 

DiahKntlon of the Wriat, 

1. Dislocation of the Radius and Ulna. — Theae boDes may be dis- 
placed, tuji^elher, either on the dorsid or on the palmar afipcct of the 
wrist. Falling on ibe piLlm, the two bones may Le Jisplaeed forward* 
on the annidar ligament ; wLile, from a fall on the hai:t of the hand, 
the reverse movement ia likely to occur. In eiiher case, the eigns are 
plain; a dorsal and a pdniar Ewdling exist, composed either of the 
carpal bones or of the ends of the radiug and uhia, as the case may he ; 
and, by rotation and matiipulLiiimi, it ia iifitertained that continuily in 
ths radius and ulita Is nnbrukoiL. The accident ig rare ; fractnre of the 
radins being a much more common result of the same exciting' cause, 
Rtditdion is readily effected^ by extcnsiun ftnd coaptation. And it is 
well to maintain retention for Borao time, by splints, as for fracture nf 
the bones, 

Subiuxathn Jhrwards ifi by no means an uncommon reault of f«l[fl 
on t)ie \ia\ai ; the bones lining not only displaced iiiwnrdfi the palm, 
but alno separated from each other. The nature of the accident is 
plain, atid reduction ia en^y. But, unless apHnls be carefully worn 
for at least a fortnight, del'oTniity by continiiance of partial displace- 
ment may scarcely Ik? averteiL 

2. Dist'tcafiori of (fn- lindlus at the Wriai. — The diBtal extremity 
of the radius may be displiiced f/ru'trrdsy Beparnlely ; reEting on tho 
Bcaphoid lume and trapezinni. The styloid iirocL?KH is no longer 
ailaaled opposite to the latter bone ; anrl the end of the radiua may be 
bolh felt and wen projeclin;;^ oq the fore part of the wrist. The hand 
ia twisted. Rfdnction is effected by simple eslentiioa ^and coaptation. 
Splinla are necesaary for subsequent retention. 

3. ffislocation of the Utna. — -DiHlocaliHn of the nlna, separately, 
may take place hackicarda: the enJ of the hone proj^^cting- plainly, 
with twistirg of the hand ; and the line ef the styloid process sbc^nng 
obvious alteration. Iteduction and retention are managed as ia ihe 
preceding accident - 

Fig. 106. DitlocniioD of Lhe ra^liiu fiirwurita. 




DIBLOCATIOS OF THE THUMB, 



4, Dislocation of the €ttt*pu&. — Complete luintion of any of the 
carpOi] bones k rare. But subluxation of the oa miignuni ami of the 
cnoeifortu boue is occasionBilly mpt mtb ; weakening the joint ; and 
causing projection on tbe back oi" the wrist, during flciion. Treatment 
is by continued presaiiro and sufiport frnin without, and by disuse of the 
p&rti for BOine considerable time. 

Dulo^atl'tn of iftc Finycis. 

By fallg HiiEtnined on the tips of the fin^re, liisli^ation of tbe 
phalaag^B is soraelimcfl produced ; and the displacement is usually on 
the dursal Aspect. It i^ mure coiiinir»ii betwe^rn the Qibt »tid &ei;o[id 
pbntaiig^E^ thiin lif!trveeti tUe Riicond and third. The nature of the 
injury is exceeding-ly plain ; and replactment is effected by eilension 
and coijpfation. To render exteneion effective, it may be oecesaary to 
affix a Jaque — a piece of tape, or the end of a silk handkerchief, ur u 
riband— to tbe distal pliaUnx, by means of tbe clove-Litcb, Some- 
times the hn^idle ijf a key may h*: wiKti advaiitaguonsly an an inalru- 
ment of reduction. Spliute arc oxpediont for some days afterwarda. 

Compound dislocations altnost alwayp are of such Heverity ns to 
demand amputation. 

Diahcatitm rifthf Thanh. 

The first phal&nx is nut nnfreq^uently dislocatt^d backwards on tbe 
dorsum of ibe metacarpal bone, and is reduced in general with diffi- 
culty, on account of the strong lateral li^'amenls which oppose the 
retrograde movement; and also on account of the many strong muscles 
— eiglit — which are connected with this part, and require to be over- 
come ill the extenfiion. Extension having betii mauitaim^d fir somu 
time, steadily, by means of a miitable laqne attaclied to the first 
phalanx^ flexiun is mado towards the palm ; and during thLs forced 
movement, elowly yet determinedly performed, reduction is uanally 
accomplifihed. It may be necessary, in extreme caaea, to have recuurse 
to BUbculaneous section of one or other lateral ligament; but such 
necessity, with the use of chlortjfonn, ruay ecarcely be expected to 
arise. 

Ilmd DD FraotarcJi, LornJon, 1^136. LcmidiUD an Fmi'tUTee, Lotitloo, IS^. A. Cooper 
on Di§lDi>alkkiiii Ani3 FriK'tbirti'j, Ijnulctn, 1N4?. Dnpiiylri^n on DSHi^ji.scri nnd TnJiini'Ji nf 
Bones, S>de!ihjurt Siitiely, Lonibm, 1847. Smith on Frai-tiinia in Uie vidnity »f Joints 
&&, Dnblin, IW7. Vinwut, Obwrvatk^ns on Surgir-ai PracIicE, &c., London, 1847, 





F 



293 



CHAPTER XXIV. 

INJOEIES AND DISEASES OF THE SPINE. 

Concussion of iht Spinal Cord^ 

By falls or bluwB, the spina! curd, like ihe brain, may sustain a 
greater or less degree of coEcusaioD ; haying its Junctions arrested or 
disordered, without uctua^l lesion dont^ tu Us struoture. The coucuuKiuti 
maj l)o citbcr general or portiol. In the kttcp caso, it ia prolabid 
that Iho wlii">l*? cord HufFurSj though unequally; the major effect being 
at and beneiilh the part struck — as denoted bj paralysist more or less 
complete, of tlie parts thence Biipplied by nerves. This paralysis is 
transient ; passing off, in a few hours — or days ; never of long duration 
when himple — th^t is, whea uol aecumpanie^l or followed by estra- 
vasfttion nr effiiBJon, Aa in the caee of the brain, reaction may prove 
excesflive, and ififlamTnutory mischief may speedily eupervene; attack- 
ing the cord, ita memhranea, or both, and ushering in a completely 
new traia of symptoma. Or — also us in the case of the brain — the 
immctliace results of the injury may all BceiD happily to pass away; 
and, at a remote period, au iusidiuus ehiunic inflaEiunatary process may 
occur, in the cord or in ita membninca ; oaueing-* in tte one c^isc thick- 
ening with efFiision, in the other purulent softening of e\ow pr^jgress. 

Treatment is guided by the same principles as in coDcusaioo of the 
brain- Absolnte qnietiule ia enjomed ; and the period of reaction is 
carefully watched. If it threaten Co prove escessive, antiphlogiatic 
measures are adopted, acconling a& cireumatancea may seem to Jemand. 
And, for a long ^>eriod after receipt of the injury, the patient must bo 
content tn use all the precantii^iiB of a prudent invalid, w> as ti* avert 
if possible the insidious and formidable remote residts, Thefic, having 
threarened, are best met by rest and pittient counter- irritation — with 
appropriate constitutional treatment. 

Sff/lc7u'rig of tbe spinal cord, ehivnic, iiisidiuuH, and intractable, ia 
no nnfrequont eontcqneneo of severe falle, or blow&j n^x>n the apinc ; 
more es^ieciiillj in thofie in the better ranks of life, who have lived 
hard, and indulged ranch ia venery. The lower limbs first begin to 
fail, the extensor muscles proving unequal to maiatain the erect pos- 
inre, and the tuees consequently ever and auon Ihreatenmg to give 
way. The feet iLre moved oddly, and are not planted oa the ground 



1 



I 



L 



OOMTREesTON OF THE SPINAL COHD. 

firmly, or with certainty nn tte Bpol intended; the legs nre tliTOwn 
outwards in stepping, und bnng the feet ilown with a slap. The body 
is stooped in walking; and the line of pro^ss ia seldom a. straight 
one. The tosvelfl gef sluggish, and the abdompo enlarges. Tbe urine 
is voided with difficiilfy. Thearma are fouiid to he weak; and the 
fingcra Mcm to 1« ^fftdually freeing themaclves from control of the 
will ; there h^ing tho same uncertainty and inpfGciPticy in doing any 
thing wiLh the iiands and fin^^rs, as was first observed in the lower 
extremities- Not infrequently the pfl.tiont is much harassed by neu- 
ralgic pains, shooting down Ihc batk and iimbs^ and Bometimes affecting 
the head alsi>. Gradually such ETmptoms increase; urino and fjecea 
come to be p&aecd involuntarily, ur ulmost so; tlic itsc iif tlie limbs 
l>wom<*H more and mure feeble and uncerlain ; the brain at Jo^it ie in- 
volved ; the mind 2;roiTS imbecile, as well as the body ; and the patient 
dies, nftea with Byniptomaof j^low compressioTL The spnal cord is often 
found more or leas affected with ratu^llitsement ; sometimce, however, 
it presents no orgaiiie le^tm. But little beneUt can be expected from 
treatment- Of heroic rcmediea, there is no tolerance. Indeed, the 
prndent practitii»nor e^ntents himself with cnjnying great tem[>eranca 
in all things ; while by the employment r>f ordinary and simple means 
he seeks to palliate symptoms, and delay the fatal issue. 

Compi-ession of ihc Sptnal Cord, 

Thie may be caused, :ifl in the brain, by oxtravowktiun of blood, on 
the siu-face or in the suKitance of the cord ; by fntctiirc and displace- 
ment of the vertebne, producing direct pressure on the cord, witli or 
without laceration of its sobHtiince ; by inflammatory esndnlions and 
effiisioEis esterior to the cord ; or bj purulent dist>rg;aniKaiion of the 
cord itaelf, the result of inflammation, Veiy obviously, the direct 
interference of operalive surgery la hero of no avail ; the trephine is 
not U) be tliou;?ht of Treatment cunslsts of expectant rest, in the 
first iuHtiiuce ; auKioiiylj looking for the earliest appearance of the 
inflammatory process; opposing this by the suitable means, yet not 
heroically — knowing that in such cases active and extreme dtplelion 
ia iil Ih^riie j and miti^aling the sjaiplomH cimuecttd with the paralytic 
state, as far ns the rG^ourecs of our art will allow. Id the case of 
eitravasated hloofl, if the immediate risk be overpassed, wo may rea- 
sonably enlerlflin expectation of a fortnnalo result. On the other 
hand, few cases of displaced frai:ture are wholly recovered from. And 
the end of inllammatory diftorgauKation, whether chronio or acute, is 

ultuofii invariably disaslrriiifl. 

FrHtcture of the Sj?ine. 
Severe and direct violence is m')re likely to cause fracture thau 




»4 



FRACTTURE OF THE SPINK, 





Yit-l^. 



dislocation uf the vertebra ; ihete bones being so intmiately connedtd 
to each other hy their wticulaticg proeeBfies, The spinous proceaes 

alone may be broken. There is liea little 
displaceuient i and the coDsequcncpe are 
but trivial- Bui fmeture truvereing the 
body of the bone, making a complete solu- 
tion of conlimjity in the spinal colimui at 
that pait,ia fraught with the ntmoal danger, 
SimcHinil injur}' has probably been in- 
flicUd, at the eamc time, on ihe Bpina) 
cord an-l its mfmbranes; ertravaaation of 
blood has taken place into the canal ; pro- 
liably there is displacement of the frag- 
ments, and further injury thereby done to 
the soft parts within. Ordinarily, there- 
fore, the mort promiiicnt si^ of spina] 
fraclure^heHJes pain, Bwellirig, mobility, 
crepittip, and departure from normal out- 
line at the hijured part — is poralysifl of 
tliofio miis*:les whose nervous supply pro- 
ceeds fiom bcnealb ihe seht of injury, 
Aocoribng to the scut of injury, the nature of the case materially 
▼arittt. Wlien the lumbar region haJi Riffered, the more proTninenl 
flyinptoiiis are — paralysis of ihe lower Hmbs, usually tt^ith loss of sen- 
sation ; invohminry "iischwn^ of fu-ccs; retention of urine; and, fre- 
quently* priapisui. Wiicn tlio injury has occurred in the upper dorsal^ 
or iintv^ crn'ical rct/ifn^ in uddiliuu lo tbe&e &\inpt<tmB there ure — 
paral^^sifl of ono or both arms, difficulty of Urealhing^ HluggislmeM of 
(he lK>nvK with distention of the alwlcmen. If, again, the fnicturo be 
above ihe I'tight of tfic jthrcnic nerve — and coniprcseion there prove 
greftl — respiration will at once cease, causing dealh, 

Au almost invariable result of spinal fracture, wherever Hluated, 
ifl n deteriorated coiuHiioii uf ihi; unii*n" organs. The kidneys err in 
thvir funeltoiL ; and the lining uiembnme of the bladder, becoming the 
Beat of cbronic cooj^slion, aseuiues a nio^l depraved condition ; copious^ 
ftrtidj turbid, ammoniflcal urine paswB iiway, with s:ul aggravation of 
the gvneral dbonler uf system. The bowels, loo, are not merely 
disleiuled and sluggislj, hiil become depraved in the function of their 
luucona inembmnc; llie dejcctivna evincing a yery vitiated character. 
Bod-eoren :iro apt to form. 

The symptoms, eontinuinj^ and graveacenl, may terminate in death ; 
or, gradually mitigating', recovery may ensue — more or less complete, 
Obviotisly, the dmi^rs ti> Hfi^ are boli many and formidable ; inflam- 
maiorj discjiee in lliu cord or membranes, — eflfushmj exudation, disor- 

tlg. I07> FndUNd t^\iit, biMcLod i ihbwiog the ibrmidAblc uhi fnUi iiguty inflicted 
1^ itiD tvnl 




FItACTURE OF THE BPINK. 



295 



gmdiatioa; BecoDcIary affections of the digestive aiid unnary organs; 
bed-sorus, and goneml exhausliuD- It need not excite eurpriee Ui find 
the averflge of recoveries estremelj small. 

Thtj treatment nmy be reduced to sjiaple princtples, Verj careful 
movement of tUo paliQiit, and adjustmont on a hard mattresBf lest 
furtlier dispUcemetit of the fragments occur. An equally careful re- 
duction of tbe diaplaccmcnt whicli is found to exist. Retention, by 
adupliition of a spUnt — of wood^ [jaKtebuard^ gntla percha, or padded 
iron — on each side of the spine, for some distance above and below the 
Bite of injury. Eiifurceujeril of absolutu quittude, autipLlogistlc regi- 
tnea, and tbo other ohvioiLB propLyluctic measures. Moderate anti- 
phlfigifltica, shiiTild inflammatory symptoms exhibit themBelveB. Miti- 
gallon of the UDpleasant reaiiUs occurring in the digestive and urinaiy 
organs; obtainiug regular and better movement of the bowels; reliev- 
ing the hiadiler by Ihe catheter, at etatod and freqnent iatenale; and 
recLifjiug the sliil^i of the uriuo, bv mineral ae'idb and other medicinal' 
nmiiua in ordinary iiao for tbut piirposo. UUiiuately — immedialo 
danirer having ]MUS6Pd by — directing- atieuHon to amendment of circu- 
lation in the paralytic parte; Ihiis preventing Bhriukiug by atrophy, 
and j*erhap& assisting in the recovery of function. TLe means usually 
employed to fultil the last inJicalion nre, fm'tioii, shampooing, ^'alvan- 
ism and eZet; trie ity, iind thi^ nsv of bLrydiuiu. Galvanism and electri- 
city are lo he u^od with caution^ howerorj it being tlio opinion of 
Hoiao, lluit, Although hy moftua of these agfiitH, muscular conti-aetility 
may (i)T a time be roused, yet thnl the amendment in in general but 
temporary, and that tie parta iillimattly lapse into a worse degree of 
im]K>t€noy. Counler-irrilaliim is som*?limes of Bcrvico. 

In the obviously disphieed spLiiiil frnctnn.', willi pjmptoms of com- 
prcsHion of the conl, it hca been piupob^ed lo employ llio trephine, with 
the vi«w of relieving the injured medulliiry matter. Re.ison and ex- 
l^rience, liowevcr, h^ive decided agaiust the procedure; inquiry hav- 
ing hijown that the c<jmpressing agent is UBually the foi'c pjirt of the 
body of the vertebra, which cnnaol he reached and dealt with from 
wilhuiit. 

Spinal Jissufc may occur, without difiplac«mcnt ; and yet mny prove 
fnliil^ from juiotlier ennso than coTicussitm. Into tht- cleftj i\ portion of 
the membranes may be received ami retained; tlie constriction acts 
as an nitititernipted exclling eanse of inRammatory disease, and fatal 
exudation or struclnra) change ensue. The case ie obscure in its course; 
anil is likely to be uniuriuinite in iLs i&suc, all remviliul moans proving 
of Utile avail to arrest an nfltclion, i>'liieK is being ever fed ami main- 
tuined by an influence wliieh ia innceesfiihlo nntl consequently insuper- 
able. 

Dislofafi/iJi iifihe Spine. 

Lnxaiion of the fiinno, wilhouc frflcturc of the proct^aes, is n rare 






applied from wtllKnit ; m by fulls on the head. Siiq^enfiion sometime!* 
cftUKt^ it^ but iiiiirL inoro mrdy thiin h gonorall)" supi>t>scd ] usually 
(bare is no (lisplnct'ment of tbe V(^rfel>rip whatever, even in criminfll 
cases — death taking: f>We from utbcr causes, 

'Ihe dbplaccmenl is easily rocogTiiBiible on rnanipidHtion ; and the 
eoncomilant eyinptoms of couiprcBfied or lorn Hjiinal cord jue suflicitnlly 
explidt. ir liff, Lir tbe ho^e i.>f life reniuiEi — ipplitL'cment is to be 
effected by ciircfu! i-stenaion ntitl cifHpt«tioii ; iifterwArds, untoward 
reRiilta nn* to be obviated by sucb nianagoment as ba?* been advised in 
ihe tase of frftclurfl, 

StibliixatloTi, or partial diBplaccmentj of tbe verlebm is by nti 
mt-finB uncommon; and m[iy take ]i\aca at any fmrt of the Epin&l 
colnmn. It is (trobably of most freiiiicnt occutrencG in tbe dorsal 
regitin ; caused by fiiilin^ on tlie breecli, fruin a cnnrtidcrablo height, 
with consequent forcible bendiiig of tbe tnnjk forwards. Thi* posterior 
Ugamenloiia apparatus gives way, to a greater or less exieni, and a 
hiatns between the Bpinous procesaefl results. Thu Kymptoins, in addi- 
tion to tlie marks of displacement, are those of SL-vore spinal concns- 
Hion ; and tlic Giibseqiient dimgera are alao such a& may tie exacted lo 
fiillow that accident. By estension^ rcplacciucnt la gently effected- 
The same retentive apparutus is then applied as for fractnrt, and mnst 

HTg. 108. DUlocfltion of the Epino; beiwwn tin- Tourth ami Pftb strviciU TerteLnr. 
Tha padpTit fifLI Iju.'kvanl'' Dvi*r a hif^h fmlin^^ ddi) iili^ttle*^ on li[a h^aiL Card (ntn. 
Oimplple pnralynH- Wui- fatiJ, within n few dnvB. 

Fi^. 109. The sirnie; at^n Ifih-mlly, 




LATERAL CURVATCRE OF THE BtTKE. 2W 

\te worn patiently for wfpks ; tl^o patient it'Biiniing use of bis lower 
limhtf vi']-y grmlniillvt luifl not till aftL-r uiiniy weeks hnve elapsed, 
TbnMi^liuut Ibc whole period of treatment, an anxiinis regard is pniil 
lo the Bpinjil cord ; and remedial meflsun,*s &rc ftdoj^ted, if neceeflary, to 
ward oif dieeoM there. 

Lateral Curvature of t/ie Spini^. 

Laterftl curvalnre of the spine ia usually hold as contrasted with 
Dnt«rO'i>oBterior ciirvnlioa ; the lalter tlie result of ulcerative lesion in 
the hotlii^rt of the virlehra^T '!'*' f<jrit>er i>ng5iially fincjiiuteted wilh 
Btnictiirat change. En the one Ihcro is nicrc chnngo uf [losition ; in 
the other, there is rhan*,'e and Iciss of hone, by Ihe results of inffam- 
infttory dijf^'iise which li^s origiuated there, II is riglit to reuietiil>er, 
howcrer^ that Iti mim' eases the antero-t^OHlenor curve is foinitl to be 
of lh(i same nature as the hdenU ili'^jilaeenient — or-L^^iii ally unconnected 
with BtnieUiral ciiaiij,'o. 

Lateral curvation may ar\&' from different eauseG. And it is 
ira|>ortant to cliiasify tlie crtpea Fiocorrlingly ; thiit Ihe suitable treatment 
may lie affordcil to oaeli. 1. PectiUcr avncalwris htq not uufrcituontly 
the cause. Iliost-, for exutuph*, wliieli eiilail a habitual use of the 
righi arui, much disproixjriioncd lo that of the left ; as in blacksmiths 
oitd dni^'ooiiH. The amsclea *'i the right bide b».-come largelj develupeJt 
aod powurful ; and iho tmpcKiiiH imd rhonihuids, thus changed, acting on 
the ^[nnal eolumn sn jw \ti i^veqwiwer tlmir ft-Uows of the opposite side, 
have (he effeet uf grailually iddueiug distort ian— it may be to a eou- 
siderable extent. Uf course, this in must liktrly to oteiir during 
adolesteiice. The remedy is ^im[de; partial diseontinniince of the use 
of the right Hlde^ with viicr^^ar^ed emplnymLLiL uf the left, ThtJ din- 
placemeaf, if recent iind fllighli can he jkorfectly removed. 

Sad hiiftitt, nf sEaiidinn:, silting, or reclining;, in an ewkwanl 
position, are very njit t> cuuse a greater or less nmouut of lateral dis- 
tortion in ihc young. The spinal column is hahihially thros^n off its 
nonnal lino of eret'lion ; aiid^ in course of time, both muscles and kicesi 
l)ecomi[ig accutitnmed to their iibuonu:il pusitioii, rnay refuse to n&Bume 
(lay other. And thus curvfltnre, both grocit aikd cnfim^ed, nifty 
bceome established, without any actual vice in the skeleton, the muscles, 
or the general fiystom. Ohviiiusly, there is one clasa of hiimau beings 
much more than any other exjiose"! to tliis fnrm of cur\'BiuTe ; namely, 
young girls occupied iu the crowded details of an impnidenily manngLnl 
course of eduoaiion. Yomjg iJeojde of both sexes are alj^o very hable, 
who arc employed in scdtulary occnpotmna in trails; qs in sewing, 
knittings eiigrikving, ciduurlnjf, Ac. The indir-ation* of trr>atmeiit are 
plain; discouiiunance of the hurtful habit or necupation ; ample 
amount of exercise out of doors ; and a voluntary ilso of ancii g)'mnaslic 
or i>lher exercises as are calculated lo produce a healthful play of the 



298 



LATERAL OUBVATUBB OF TKE SPINE, 



^nerol muscular Bjslem, and moro eepcclal]^ of the mtisclca of tbe 
Inmk aiid apme.* And by means oi light ardcles of drees, fjifibiuaed 
and worn so aa to attract the paiieni's notice to the tlirttatened defor- 
mity, while at tlio same time they warn oi' the nogligcnce ar awkward- 
ness wliifh hftS led to it, disuse of (be bahita in question may be 
greatly favoured. By Bome, tbo influence of a pulloy and weight, 
horiaoutfllly extended on the oi>]K>fcite side, is made to act c^jrrcclively 
on the curvL\f But all cumbrous apparatus — in the Bbape of etaya, or 
other inachiucry — are plaialy to Ihj avoided, as likely to prove most 
hnnfnl. 

3. Hitherto we have spoken of Bimple deformity. Now wa have 
to do with disease- General Debtiit//, however induced, in the young, 
IB u frequent cause of lateral curvature ; insnffitient food anJ clothing, 
extess of confinement and work, febrile or other affections leaving the 
Bystetn exhausted — are all causes of such debility, wiih its consequent 
injuri(}U& iritlviencc on tic spiue ; and to thc^e all ranka uf Ijfo nre 
Bnbjoct. The niaflculnr system ^ow» especijilly iv^eak ; the extensora 
of the trunk are uncqujd to the taak of duly mainlainiug the erect 
posture ; and deviation frcm the strui£,di[ line results — at first occasional, 
afttirwari-la habitual, and ulliniately confirmed, ]n the previous 
examples of lateral eurvalure — uncojuiecied with actual disease — the 
curvation btgiiis iisually io tht Uoreal Tcgion, and ia m^nly wlnated 
thero, Unt in this cawe^ iho heginninn- of enrviition is more likdy io 
take place in the lumbar region — ai the lasis of the pyramid of snpimrL 
An inclination ia ma^le to either side ; then, to atone for that, ^m 
opposite curve ia made in th« duraal region. And, not utifreijuenlly, 
there is a third ultimately est ablishe<.l in Iho cervical, in a direction 
oppuseit to that of the duifiuh As th(- amnunt of bL^mling increuHeSi 
rotatimi at iho pame linio generally takes pI,ioe — tho Totation Iwing 
towards (ho same side as the ciin'e ; Ihe heig-ht of the spinal column, 
loo, greatly decreases; and^ in consequence, serioua chjingee happen 
to liie thoracic and abdominal viscera. Tho ribs expand on one side, 
while they are closed on the other; mid lliey fall inwards, narrowing 
the chesi in its latur.Ll direction, and prodncing prumiiLeucc of the 
Etoninm and of iha t'os^tal cartiUigus. Tho heart and Inngs become 
incDmmoded, and labfinr in ihi-ir function. Thfi sliTnnm, Ion — with 
its co3tal appendages— has approached unnsudly neiir to the pelvis; 
the ahdominal spnco is naran^ed in cnnseqneiiuc, and its organs are 
injuriously affected- At first, llic spinal ehmige is chictiy in the inter- 
vertebral spaces; and the deformily, at that thne, is capable of buiag 
undone, by epplianees from without, or partially at toast, oven by tho 
efforts of the patient. Bnl, by anfl by, the Ixntfls become couBolidiitetJ 
in their new relation ; interstitial absorption taking place at the com- 
preBsed points, while corresponding espantion or gronlh occars ffil_ 

* B^t U. UaontK, Loncd, Xu. L^Jl^ p. 1% ci Kq. 
+ Dr. Lkown pf Bnitou, U. S- LiUK-el, Ho. 132!>. p. 178- 




LATERAL CURVATURE OF THE BPIHB. 



3Sfl 



those wbich are froc; smd then (he defDrmity ba8 become fixed and 
irremediiihle — a circuinBlance of very impurtant and obvious beating 
UQ the qiiestioD of treatment. 

The inclicatioufl of Irentiuent are directed fully more to the sMo 
of the gcnernl GyatGin tliao to the pnrt affected- A tonic re^men is 
patiently persevered in ; at the same time, the deficient extecsors are 
to be roused by friction, and by snilable exerciKe; and from time lo 
time, by mMiiipulation, a rcstorntion i<i the normal onlliue rf the spine 
is to be attcmpled. To niil iu \ho. fulfilment of the last indifalion, a 
light uiechaEiical uonlrivancu maybe octoBio nail y employed, restorative 
yet not oppresaivp, 1!<l1 nil GiimbrouG or ctmtining apparatusi con- 
tinuously worn, mnst prove jirejiidicial ; the mnscles, alri^ady weak, 
will be enfeeliled more and more ; and the originiil malady cannot 
fail to sustain aggravation. Goud <liet and clotlung ; re^nilatiun of 
the bowels; e^iKJiure to good air; jiididons rise of medicinal tonics; 
friction of Ihe back, noting more especially on those imiBules which 
eeein ^lo^il doficii^nt ; hoflllhful eseroi'ic, buth of the goriorfll body and 
of the muBcles of the truiik — fibort of fatigue; and wcamonal allempla 
at readjuatmenl by mechanical appliances — constitute the most import- 
ant means towards alleviation and cure. Myotomy has been practised, 
both jn this and in other forms of spinal diHtortioa ; bul with no good 
reeulL The espeneoce and judgment of the profession ore alike op- 
|>Deed to it. 

4. A diseasrd condition of a niiucle or htitie, in anolhr.r prtrt, may 
cause cnrvalure of the spine. Thus, a rigid and contracted state of 
the sle mo-el eido-mastoid muscle of one side, producing the Btato called 
Torticollis, is very apt to causo epinal curvature^ as has already been 
n<riicvd. TJxe remedy is aiiuplc ; liy division of tlie uilending muscle. 
And agJiin, shortenini" of a lower limb, by morbus coxariua, op by 
ill-united fracture — unleas atoned for by suitable mei-hanical contriv- 
ance — can scarcely fwl to cause more or less diatortion of the vertebral 
column. 

5. Jiu-Ms is certainly not the least common cause. And the 
unrvatiirea bo occusioned are at once the most rapid and decided in 
their progress, and the least amenable to tveatment. The peculiar 
characl eristic w indication of llie rickefy stale; — ftlmmonH complexion 
and character, and distortion of other parla of the skeleton, as well as 
of the spinal column. The resnlta of extreme spinal cun-ature, usually 
with rotation, are rapidly developed ; anil, at ttie same time, the pelvis 
Aud luwi^r limb^, as vmU us the clavitdea and the eu^HTior extre- 
mities, are more or lena distorted, Uanally, the direetion of the 
spinal curvature la lateral; but it may bo an lero -posterior. The 
treatment — prophylactic and curative — is comlucied on the ordinary 
thci-apeutic princijilea. It is here that the use of mecbanical aids, 
in the t^hape of elays and beU.fl, is not only allowable but highly 
necesssary — whan the patient is in the erect or Hemi-crett posture^ and 




3O0 DISEASE OF TIIE BODIES OF THE VERTEBR-t, 

eepeoially when exercise is tuken ; yet reqniriDg mncli prudence And 




Bkiil boUi iu their first adjURtmeTit and Biibsequent nse. 

Disease of Vie Bodies of Vte Verttbrce. 

Inferstitfitl ahsorpt/on frequently occurs, in connexion with sim[>lr 
curvature, a£ iilreftdy staged ; whereby a distortion, at first rt;mediab!e, 
becuines iiUimalely confimied and nnallerable. It also occurs as a 
primary affection, in tlio bodies of tiic vertebra?, as a pixdmle to carioiia 
ulceration. More rarely, it psiiits as a eeparate and diptiiict djfiease, 
cansinff displact^mcnt by curvntion forward? at the afiected part ; and 
deposit, rollowin<r on absorption, afier a tiaiCT confirms tbc curve by 
consolidation. Treatment is by i-est and gentle counter-irritation. 

Continuous Absorption and Stmplt; Ulceration oet?nr in the bodies <if 
tbe vetttbra^, as the reauUa of pro&suru; the funner ^jFltn is caused by 
the gradnal action of an aacnrismal tumour; tbe latter may reenlt 
from the more speeily oiierution of the same caur^, and is sure to be 
produced by the pressure of an abscess. Healing takes place, on re- 
moval of tbe cause — if that be in our power. 

F{e& 110 (uid IIL Penuansat aurrAtnre of ibo spiat?, with niatinn, profl<< — ' '-^ 
Riokotfl. 



CARTES OF THE VERTEBRA 



301 



Caries oftlif^ ( 'tr i'j^frrfp is a moat formiJublu flffecticm, and unfijrtjt. 
tialely ni*t of nire occnrrenre. Il is tKe - 

ordinary cause of sharp antero-poh tenor cur- 
vature usuftlly termed "lingular;" aome- 
times flFtrlliutablo in its origin to external 
injury, Lul often u [icon Elected with luiy 
aflaignfiblc exciting cnuAc. The cli^am:; 
foUoWB the ordinary eoiirae ; RometimeH 
limited to one or two bones; often involv- 
ing almost the whole chain. Its most fre- 
quent site is in the dorsal region. Usiiiilly 
it is aasociiUetl with^ and probably dejii^nd- 
cnt tjn, tiic almmoiiE diiitheRia. Obucnro 
Bpinal Hymptorns gpnersilly precede; psun^ 
iineasineas, numbness, and weakueBS in Uie 
limbs ; spaaiuodic Iwitebings ; obstinate 
bowela ; alkaline urine, with trouble in dis- Eig, iia, 

cliar^g it. In the p;^rt there is dull uueaaineHS; and ultimately pJiin, 






which ia increased by prG8!4uro, and reiidei-od intense by sbarp percussion. 

Fig- HlJ. CoiitiDuniE9. flIiQorptiDn iUiiBlrat«d bv the in-ctsuK uF hji uirlEc nn^iiritm an 
Uio bodiu or ike VL'rtcbrrr ; n, Ihi? axz\\ nf t\iv Horta- h, Uia dedcetidm^ aorti; c, Eho 
vtfiiebrd colimin. Oppoaili? rf, llic btKli*'>* of lb* vprlflirip an? necrx cxoivftl^il, *'iiti cor- 
rvdpnnJidg pmr^-flic* of Uio compreiaipg clut ,- ivUilr ihe inlcnerttbral aubBlaiici-o, ma- 
ceitafully rc^lHlia^ (lie proA^nTFj prciJi.H:l into cttrn^AjioDiliii); (k'^jrv^^ion^ (if lIli; Hbriii. 

Fi^. \\l\. Cnripji of iho Ycrtcbne; macerated ; 1li<^ bodies o^cl^naiv^y duti^yed; 
uiuiknl cur^jiiJun fitrnurd^, 

b'iK-114. TUt} eflme dutiag life. Aneuktiuu, 





302 



CARIBS OF THE VERTEBRiE. 



The ^ftit is totlenag jiiiJ uticerlaiu; with the back kqit pecnlinrly rigid, 
BO as to avoid motioti t>f the diwaacd vertebr». Often a distr4^ssi[ig sense 
of constriclion is felt m Ibe chest, as if this were girded hy a tight cord. 
The armplomB of pnnilyBia manifeet tbemselveB gradnjtlly ; nffeeting 
different [mrts, according lo the site of the vertebral dLwftse ; and 
iisnftlly motion is impmred befnre Bensation — as can readily be undei^ 
Bton<l oil reference to the anatomical arrangement of Ihn nerves given 
off from tho apinftl cord. Sharp curvature, fon^-rmlsj Bj:ivBnccH more 
and more. Tbe tnittter, in which the carious mass is batlicd^ accumu^ 
latea; and, seeking an outlet, i>oints at some part of the snrface — 
directly, on the back ; or at eome distaut point, 
aa ill the loins or groin. The uUimate result 
maybe cure by anchylosiM, In the slighter cases; 
the curve remaining permanent, Mutli more 
frequently, the issue is fatal ; ocuiirnng rapidly, 
by the effects on the fpiaal cord; or more gra* 
<h;ally, by hectic and exhanstion, 

Trefltment conaists in afTorJin^ absolute r^st 
10 tha part, by confiriement to tbe recumbent 
j'osture i with attention to the g-eoeral health, 
and patient conlinnance of cod-Hver oil. In 
tha avowedly strumous cases tlicre is usually au 
intolerance of all forms of active comiter-irri tui- 
tion, which threaten lo accelerate the fatal issue 
by exhaustion ; and, in such patients, we are to 
content ourselves ^Jtli rest and general manage- 
ment, looking gloomily to the result. In all coegb, caiittic ieeuoB aro 
only ser\iceahle at the commencement of the disease. The prone 
pofiition is usually preferable lo the supine; as relieving the spinal 
column moro th^iroughly from the su|>eri missed weight, and proving 
favom-able to venous i-eturn from the lodies of the verteT^ra?. And 
*' the proue couch," (employed almost constiullyt day aad night, will 
be found in moet oases a great asEisiance in thu treatment ; becoming, 
afler a lime, not only not irksome but absolutely agreeable to the 
patient ; and of course eo managed as to avuid, as far as possible, even 
the very api^earance of restraint. In all cases, mechanical a<li[istment 
of the disl<irted spine by force is manifestly at variance with both 
surgery aud sfasc 

Caries of the up[»er cen^ical vertebra? rei]uirea the most careful 
mAuagement : lest, by sndilen motion, displacement should occur, 
causing fatal compression of tlie upper part of the cord. The patient 
Be*ms to bo inetinctivcly aware of this hazard; and, oti moving bin 
head, always supports the cUin carefully on the bflud, while the whole 
body — as a pillar — is made to turu iu obedience lo the direclioii of its 

Fl^, 11^. Caries iif tbe Vi?Ttel>Tfi ; prevtoiuly lo maceraUon. Thn lorta ovtrlayi tho 
,-v^t of (hfl atweBi. 







LUMBAR AVD PSOAS ABeCESS. 30'^ 

Cftpitftl. Hot© raeobanicnl contrivnnco is most suitftble ftnd neceiteftry j 
in order t/> giiard iLgdtist m]iL<J<;]i motJoti, and ut tho tmine tlmo to 
relieve the diseased boiics from the weight of tho Lend. By thin 
and couiUcr-irrilfltion, with dire attentioii to (ho general healtli^ cure 
by ancbylijsis in to be sought for. And Ihougli in no caae our hope 
need hv ^all^^tlt, ticillier io aiij need it j^-ivt pltvto to detp^iir ; seeing 
tliat our iimscuitiB ^how cures \>y anehylosiH imdor circuinj^lnnci^s tho 
most imrMvournhle — ihe a|piiiiii cord having atcoTnmf>riatod ilM'lf to 
great dis[>Iac(?mcDtf as well us loss of snhHtancei aifccting even the atlas 
and dcntata- 

Lumlar and Psoas Ahsc&s. 

By Lvmlwr Abtcess is underfitfforl, n collection nf matter pcjinting 
wraiewKcTc in the Iiimhar region. It may ori^^natp wholly Id tho soft 
imrtfl. More frequently it ifl the residt of cnriea of the veriehraa. 
Treatment depends on the natnn? of tfie case. If tlicre he no prospect 
of nllimate uiire^ no opL'ning Bhiuihl he niade ; the ordinary paHJjitives 
are to \)Q ftdniinistered, and everj- cure is to he taken to keep the inle- 
gumenla eiiLiro. If the case preeent a favoiirahlo asppeti on the con- 
trary — the amonnt of dieejise in the spini- ft<^prning uli^ht, and the 
syslrm yet toleralily mhiist — a free evaeunlion whotild be mnde hy 
puDctiu^. By the inflammatory disintegration following^ oc Huch 
opening, we fire mo^^t likely to obtain sncli sponlaneone change in the 
Plate of the bone, as will admit of the healing process. But the proeess 
reqidrea iui anxioua watchfidncsSf lesL it involve the ^yj^lcuj in a 
dangerons amonnt of diBtiirUince, and It-st, also, hy t'xcpss, it prove 
prejndieial to the affected pari. If a case present itKelf, in all local 
respects promising, bnt with the R3'Btem arddcnlally bw, the opening 
should he delayed until, hy time and suititble manngeaientp the consti- 
tniionul powers have hcen sotnewhat restored, and a tolerance of the 
remedy regained. 

When the matter eonnoctod with vertebral diGeaso pninta in the 
groin, having descended along the course of the psoas mnsL'le, the affec- 
tion is tenned Psoits Abscess; bnt it, too, oiay oecationjdly he found 
nnconnected wilh disease of bone. Trentment is tho same as in the 
former instance. Under care, cod-liver oil, and the prone couch, eome- 
timen wonderful recoveriea take place ; even after long conthined dis- 
charge, 

Sjtma mjitla, or Hifdrofat^hitis. 

This ifl a congenital malformation, ntually Kilniited in the lumhar 
region J bnt it may be in the doreal or sacral. Tlic posterior part of 
one or more vcrtebrie ia deGcient; iLud, in coasequcacc, the luemhrarieB 
of the ccird protrude, cooetilnting a ttiTnour of greater or less Biae — 
composed of the nrdJnwy integuments, the changed spinal membranes, 
and the spinal fluid secreted m excese. In other rcEpects, the child 



1 




1 



RPINA BIFIDA. 

may bti fully and well formed- More freqaenily, it is ollierwise de- 
fective J tlie lower limbs, especiallj being nhnink and pftralylic. 
Ufiually the tumour onlargea, by flcoumdatij>n of tbe eontdnod iltiid; 
the inlcgiiment thins and ulcerates; the liuid contents escftpo und the 
taniour collapses ; jui ostlR^nic inBammation nemes on the t^pinal eor^l 
and its membranes; and the patient j>eriahes either directly in conse- 
qnencc, or by heptic. In the more favoursible cases, the liimoiir may 
enlarge slowly, if ot all j and ihei child'a grnwlb may advance tiuiiiler- 
niptadly. Sotnetimes, by spontflneoiifi nlceratiou, a very niirmle 
apertnre is formed, tiiroui^h which the fluid contents slowly drain away, 
the Inmour gradually shriukingj and the jmuIs becoming satiBfacl4trily 
consolidated. 

Curative troalment is attempted only in those cases which afford a 
reasonabli! jiroapcct of ftuccrstifiil isane. In some caws, it is enough 
to palliate and prevent inorease. Tn others, we get rid of th^ a^elUng, 
hoping that the tissore in the spitial (■(»l(imn may close ; or, at all events, 
that such conaolidiition liball lake place as may efiectualty prevent 
recnrrence of the prolniMion. 1. By Bleady and uniform support and 
pressure from without, not only is increase prevented 5 absoqjtion may 
also be occiuiimed ; and the tumour Laving becotnu slowly di&cnesed, 
an opp[>rtunity may he tliuR ^ven for closiiro iff the vertebral hiatus. 
2, Along with the use of prfs*<ure, occasional puncturing of the cyst 
may be iiractised, 90 iis tg espe<litt the process. 3, The fluid may be 
at once drawn off with a trocar and camda. And it has been further 
propost'd fiubseijuently to inject, iijiline, ra for hydrocele. 4, By 
inchuling the pjoniinciK^c of die turuour lit tuo eilipcical incisions, which 
penetrate the whole thii^knetia of its cuveringB, the fluid is st onca 
evacnat*>J ; and then, on bringing and retaining tijc margins of the 
wound in contact by means of BUture^ such a degree and kind of traction 
is made upon the parts Iwneith as may favour, very much, the desired 
closura of tlie sjnnal fisstire.' In dissecting away (he part included in 
the elliptical iutislims, caic miisl be taken lo injuii; the nervous ex- 
pausi^na on its interual afipoet as litllc; a^ ^^a'iiiible. The hoaili too, 
shuuld not ho kept \i\^\\; otbcrwifie the fluid of th" Rhcalfi h apt to 
escape ton suddenly. This last oj«.Talion is warrantable only in those 
cases in which the fissure is slight, and other circumstances are favour- 
able. After swch a jiroceeding, ns well as in the midea of treatment 
by puciclare, obvioUT^ly llicrc is unicb diinger by uillfimraatory scianre 
of the flpinal coutcala — which baa to bo guarded against uccordtngly. 

The spinal colnmn bus occasionally been found affected by malig- 

- DLnoLTiu], Guzflfte UtiUalPiJe PutIb, Juillet 31, 1841 ; uld HriL and For fi«T. 



WALIGSANT DISEASE OF THE SPINK- 



305 



nant tumour;* an aflectioa which is fortunately rare, seeing that in 

all cases it must be quite incurable, 

Sliaw Lin Distortions of ILb Spint, Lend. 182a and 1825, C. Bdl on Injuriea of thu 
Spine, LoniL IS^JA^ Lawrence on Dulocfltiona oT the VFTtf^hraif KIcd. Chir, Traiu- vol. 
xiii- 1S2a Tmdti un Tf<?urii]t:i'' DJ6t:flWd, Li>tid. 1S2&. Bi'uti?, a TreatLae uii rfftrni^kjEd^ 
Ac. Loml IS'30. StafTordon Eluurkfl. DiaciLsvi, and DLttortJ(hn?of the Spine!. Lond 1832. 
Brodie on Iiijuri*^ of tbe Spinal Card, Mi^, Giir, TraiiB. vol. :tx. I837> Gueiin, Gazette 
Medicale, 1S4U, Not. 14 and 15, Uevriti, (JoflC-* of Spinji Ultiilji, l/»n<i, Wed- trazeite, vol, 
■xxiv-. IR44. |^n-43>1f' on Gi]T\'3lure nf tho S|iiiio, [j^nd 1S4T- St/in1i>y on Diii{!iiFi(>a of 
the Bonefl, Lond. 1&49. BLtbip on Di^formilietK of the Huiniui Boly^ Lonrl, ia'>l. Tam- 
plm on Lateral Curvature uf ttie tipinu, Lotiik- 11^3. Pirrie, Principles BJid Practice of 
Surgery, Load. 1S6-2. BTodio un Injurioa of tita Spin»l Card, Mi^iL C^r. Trana. vul. idd* 
Brodia on CurvaCiirefl of the Spint, Lancet, No. I'ilS, ct ttq. 



' Uedico-Cldrurgicfll Tmuuct. vuL \i. tit. S. 




CHAPTER XXV. 



INJUEIES AND DISEASES OF THE CHEST, 



Fracture of the Rihu 



The ribfl are very liable to fraclure ; by a blow, or ftJl, or the appli- 
cation of crushing weight ; and the ordinnjy eile of injury is near thft , 
piiMle of the boi^ts^ The signa iire, pain nt the p&rti usually wilhj 
iliG(H>lomliim mid RweUiitg ; difHcnlt breuthing ; fitll iDepimtion im*i 
praotirubk' — thi^ atluDipt cansing great aggravadon of pain, witliJ 
sudden catching of llie Ireath ; crepitus feU, when the palm is hel4] 
ovor lliL^ iiart, during respiratory movement. Disiilneemcnl ia seldomj 

great ; and is nlmost always in*! 
^vards. The injury ujay he com-' 
pound, with correspotiding wonndj 
of ttie integuments. M<^rfi frequeutli 
it is ill amannercompomid, by wounii 
of both pleurre, and conseqneiit gooh] 
mnnicalion with the lung, the int 
meiils remiuiiiug t;u(]re. TTnde 
each circimislan^cE, omphysema caa ^ 
Bcnrcely fjiil to occur, to a greater or ) 
leas extent; air escaping ontwardlfJ 
from tbe hmg', and becoming infil*J 
tratod into the Bubculaneons areolar] 

?^M j J liHHiJc — piidiiif^ ujj ibe surface of i 
^i tHt ^bofit, and proh.ihly also oxtendir_ 
^ to tlie nark. Triflammatfiry nJTectioEi] 

3 of tlm pleura is not tinlikoly to super- J 

3 vene, as can readily be understood. 

^ The olijeotH of Ireatment are, toj 

effect and mainlain replacement, to] 
^*'*"' prevent molion, and Lo fiverl infloui- 

matory or other untoward conseq^iienceB. A Cdmpress is Iftid along tLo 
stemnmf so as to make that surface equally Bulicnt witb tbe epijioug 

Fig. IIG. Ofnenl 4!ia|»hyit«ma of th^ wtnlj^ Burfart, aTtfr w^tuufl of ihe ri^hl tiiie ixt 
Uifl cheaL After LAnncr. 




PBACTUIIE OF THB BIBS AND STEKNUM, 307 

ridge of the vertebrs ; and then il LrcMwt flflnue! roller ia applied tightly 
round ihe chewt j llie efTect of such deliiration being io arrent reepiralory 
movemeul of the ribs^ and to force outwards tba frag^aents of the rib 
or fibs — not only |tWiiig Ibtni in more accurate contact tbaQ tbey 
otherwise would be^ but aho removing their ^hnrp estrcmitiofl from tKe 
pleura, which ihey might senously injure. In severe caacH, when the 
cavity of the plenra contaiuH mncli extravasated blood, bandaging must 
be conducted with great caution, lest it seriously aggravald the already 
existing^ dyspntea. Ri^^d autiphlagifitic regimen it^ enjoined ; and active 
iLati^hlitgiHticH are not delayed, if inliauiinatory ucceuaion ihreaLeti in the 
cbcet. Cough, sneezing, and other itivuluutary movements of the part, 
bbould be avnided, [f po>ipible ; and eonHnemcnt to bed \s expedient, 
dnrinj^ the first few days. The baudaging is likely to limit or prevent 
trnphyeema ; but if this prove cicesflive and inconveuieut, relief may be 
obtained Ly punctures. Ordinarily, it does not occur to a great extent, 
aud gradually iiibap|H-ard, pn>bably by aWrptioit- 

Dislocaticm of the Ribn. 

Sometimes, but rarefy, the head of the rib is dlNplaced from ibs 
connexion with the apinid column^ without fracture. Displacement 
a usually slight. And ibe injury resemblea fractnie very closely, 
both in its history and trojitment. 

f\-acture of the Slctnum. 

The Btemnm is sometimes broken by direct viokMLce, and displaced 
iowttrds. Tbe sigtis are plain; dtfunnity by displacement being at 
once diBcemiblo, ai^d crepitus taking pliwe during respiratory move- 
ment. Treatment is as For broken ribs; hut vvitliont aity compress 
over the broken bore. And there is (he same necessity for watcliful 
itnxiety as to the state of the thoracic contents. 

Cariei and Necrosis of the Rih and Sternvm. 

TiiPHe bones are liable to caries and neeroeisT in connesion wJtli 
injury, and ha results of mercurial poison — with or without Byi>hilis. 
The (trdinary Iroatmcnt has to be put in firce ; except in those cases 
of cfironic caries in which the disease Ls ^^Hght, and has been of very 
long duration, in a feeble syatem. Then, sudden suppreaaiuu of the 
discbargo, by healing, would bo apt to prove injurioas; and it in well 
to be conten1<!d with mere pallialion. In cases, too, where tlie affec- 
tion of boae is secondary to suppurative diRcase of tlie chest, all heroics 
directed against the caries or necrosis must 1)6 abstained from. The 
external disease it^ but a sign and sequence of an internal and much 
more important disorder. 



i 




WOUNDS 0/ THE CHEST. 



When opemtion on a Jificnsed rib la neccss&Tj^ freedom of mani- 
pnlalion is favoured by the previous condensation and tliickening of 
iLoae parte wLiub Ho Iwlween the bone tmd the pleural cavity. 



Semia 0/ the F^ngs, or I^ievmocfle. 

This mal-position may be ; h Congenital^ from defective develop- 
ment of tbe thoracic parietes; "2. Traumatic, a wound having left a 
portion of the jiarJetea optu to protiualon; 3. Consecutivfy fallowing 
fracture of & rib, ur perforntioQ of tho chest's wall by abscess ; 4- Spon- 
taneous, protrusion taking place througli an int«rcoBtal Bpace, dining 
the excrtioD of couglung-, or throiigli the natural aperturea at the root 
of tLe neck beside the large Lloud- vessels. The intercostal spaceH 
most frequently affected are the seventh, eighth, and ninth, at their 
anterior part. 

When slowly formed^ the prolrnded port acquires a sac from 
the pleura coatalis; and, from a sniall beginning, may come to be of 
great size — its dtmensions greatest during forcible cxpiratioD. Auh- 
cuUation reveals nothing ia inspiration ; but during forced eitpiration 
an inteuse vesicular murmur is beard, similar 10 that of normal iDBpiia- 
tion, and Gometimcs accompamed by a kinil ijf crepitaut rdie. At the 
sajuc lime, too, an impulse is giv^n to the hatid^ and the ^* vesicular 
rustling" may be felt as well as beard. 

In the trajmatic form, reduction ia to be effected, if the protruded 
portion of Jimg be iu a fit state for replacement. Otherwise, it ia to 
be removed by iocision. If left to ilself, the i>art will sphacelate, and 
apontaneotu^ cure may result. No real strangiilallon, however, occurs ; 
ai^d on this account prognosis is moro favourablo than in aWomli^al 
hernia. 

In the other forms, the tumour is reduced, and a firm compress 
and bandage conlinaously worn,* 

Wtnmdsofthe Chesty 

These may be inflicted by the tbrust of a Rhnrp instriiinent, by the 
penetration of obtuse bodies, by gunshot, or by fractured rib. Danger 
19 great both at once and secondarily ; imnietliately, by loss of blood, 
and by entranee of air into the pleural cavity ; subsequently, by io- 
flaumiation, aud its results. The latter danger is ihe more serions. 
And the general statement may safely ho mndo, that in the early 
treatment active an lipb logistics are mainly to he tnisted to; iinlew 
decidedly contra- indicated by special circumstances of the case. Pene- 
trating wodnds by sharp instruments, affeeting the lungs, are always 
formidable by bleeding. But, in the case of an obtiise body penetrat- 

• Vide M. Morbli^Lavalek, Blfm, de la Soc, Je ChiroTB. ih Paris, 1847; anJ 
Brit and F&r- Mwl. CUlr. Ef\. Jiiu. imSj p- 13^. 




WOUNDS or THE GHEtfT. 309 

ing, thfl elasticity of (ho lung savoa that tiaaup from injury whioh, 
froTn a sharp |iointed bmly, it could n^t fail to Bii&tam. 

1, Wounds of the Pleura Costalis. — If llie intercostal artery have 
been wounded, blceiling ie likely to be tranblcsome. Tho Iobb may 
bo exccssivu through the esternal wDuud ; or blood, acciimuJating 
witbid llie pk'ural ciivity, may cumpreas the lung, and constitute a 
dangeroiiH bremato-thorax, Tbia jHJiiit, therefore, should engage our 
first fttlenlion. And to securo tho vessel, one of two methodfi may 
bo adopted. It and its accompanying rih may be included id the 
Qwse of a ii^ture. Or, a linen baEidage having been placed over tho 
part, a Pjld uf it 5b pushed into Ihe wound, between the riba ; and tha 
linen pouch ^itliin the pleural cavity is cniinnied with charpie, by 
means of a probe or directory then, tightening; the bandage, and 
securing it finnly round ihp chesl, Ihis internal ping is nuide to com- 
prea* tlie vessel and occlude ita orifice. But, indeed, tha dangers 
by TTound of thia vessel aeem to havo been somewhat overetafed ; and 
in most cases ordinary hemoatatictfi It is probable, will not be found 
to faiL* 

Entrauco of air by tbe woiind, and accamulation of it witbin the 
chcutj are to be fLVoidftil by enrly and accurate cloBurt* of tbe wound. 
Otherwise, tbe condition of pneumo- thorax Ifficomes established; the 
Iiing is compressed, and made to collapse; respiration is consequently 
rendered imperfect ; and the other lung, having suddenly a great 
amount of additional duty tbrown upon it, labours in its function, 
becomes dau^eroiisly congesttd, may jjrove apoplectic, of is attacked 
by violent inflammation. TheflQ im mediate dangers having been sur- 
passed, others remain. The wound, suppurating, may lead to inflam- 
matory aflecliou of the pleura or of tlic lungs, by eitenaion of the 
inflammatory process; find this hM to be guarded against by antipblo- 
gislic regimen, in tbe first instance, followed, if need be, by veneaection 
and antimony. 

2. Wounds of both Pleura} and of the L^ng* — The dangers bts 
Still by blood, air, and inflammaiimi. There is now a third outlet for 
the first; by the bronchial tubes, as well as into the pleural cavity, 
and through the external wound. And Ihe Heeding, coming from so 
vaaciilar an organ as the lung, is likely to prove formidable. The 
usual signs of wound of tbe lung ure — a stale of Hjslfin liorderLug on 
collupec, difficult breatLing, great auxicty of countenance, and expec- 
toration of florid arterial bloiMl. Bleeding is dan gerona, by di'ect loea, 
and by danger of ha?iQa to- thorax ; and also by risk of acciunulation 
in the bronchial tubes, or in the trachea, during tbe stage of collapse, 
AHerwards comes the peiil of intense mflammatioD in lang and 
pleura. And, lastly^ by iirofnse and continued dlBcliargc from Ihe 
suppurating wound, tho jiatient may perish under the oyinptomB of 
pluhisioal hecLic, Tbe first danger is met by rest^ quietude, nnd rigid 

* GuElirie nn ^ami'li nf Ow CIjphi, p. 104. 





310 H-ffiUATU-TUOKAX. 

•QtipLlugiatic reginieu ; recourse being had also, if not-d be, lo more 
direct mL'ana of con trolling the bomorrhiLge — Jeri^'alive vonesecHon, 
nauBeantBj acetate of lead anil opinm^ &c. Rallying and reaction 
having occurred, antipblogfislics come into iise, and often not epar- 
inglv. Hectio having threatened or set in, a corresponding change 
mast bo made in t[ie treatment. The local management is simple 
throughout. At fii^l ciireful exaiulntttioo of tlje wonml is made, in 
order that no fureign matter may ho permitted to romiiin. Then it 
is covered by tepid water -dresBing, retained by light bandagingf. And 
the patient is laid, and directed to remain, on the wounded eide, so as 
to favour outward eacai>o of discharge; while by this pofiture, also, 
adhesion is fuvourcd between the corresponding wounded portions of 
the two pleurK, to im to shut off the injarvd part fiuni the gtneral 
coEtitl cavity." When coctntion exists, oa in gunshot injuries, great 
watchfulness is necessary at tbo time of the Bt'paratitm of tlotighfi, lest 
secondary hemorrhaj^e occur, Small dozes of aconite are of use in 
averting this; by subduing the febrile eicttement of tbe circulation 
which usually precedes, Emphyseuia may occur in one of two ways ; 
but is w-ddonx sudi a& lo re^piire lUrett tri'almeut. Air, escaping from 
the pxilmonic lesioxi, may not be wholly discharged externally; or, in 
a valvular form of exlemal wound, wr may enter more readily in 
inspiration tliim it cun esciL])c during expiration ; and, in either case, 
a porlion i« liable to be infiltrated into the subcutaneouB areolar (isaue. 

HcEmato- Thurax, 

Thifi term denotes an acernntdation of blood in the plenral cavity, 
causing comprefision of the corteRjKjnding Inng, aad the dangerous 
consequenceH of this, already noticed. It may be produced by apOD- 
taneotis escape of blood, through ulceration — as in aneurism ; much 
more frequently it is of traiimfLtie origin — by wound of the lung, or of 
an intcrcnrital artery. If nmy he either Eimplo or com pound j the latter, 
if the result of a penetrating wound ] the former, if taufted by puncture 
of the lung in a casa of fractured rib with much displacement of the 
abarpends of the bone — the Jniegtiuient remaining en lire. According to 
the extent of iLccumulatton, I'csjuration is more or less oppressed ; there 
is dulncss on percusdon on that side, and no respiratory mnrraur can 
bo heard ; on the oppoeitc side, respiration is pticHU / the patient lies 
oolyon the aflectpti eidcj aud the corresponding chefit has oflen been 
observed of a puqde colour; the countenance in aniious; the general 
fiurface is cold, pale, und bedewed by clammy sweat; and there is 
feeblo pulse, with cold extremitiea, and other signa of serious lose of 
blood. 

If tba affection be not compound, aud slight in other rcspecte, 
treatment is analogons to thai of sai^gnineons collections in the external 
• Gt-TBREE on Wound* of rbe Cbat, p. G3. 




I-NEUMO-THOJLUC, 



311 



imrta of the body, fallowing LruiBe. Wound of the aurfa^^e is rarefnlly 
abalained from, aud ^adnal diHaiJpearaaco hj obaorfjljon [jjitieally 
ftwjiited. Venesection is advisabloj unless wben specialiy conlra-indi' 
oated; first, to arrest bleedings and bo to limit tbe accumnlalion ; 
HecoLidJvi to dimiiii^li tlte amuimt of cirt^ulatliig fluid ill thf? laLourlug 
sound hing, and at tlie eame limo ti> ayert or mitigato inflammatory 
diseaAQ in all the injured foxiA. If, however, tlie fltcnmuIalTon be 
obviouaiy gr^at — as evidenced by the amount of dulness and fulueas 
of the Bide, and by the oppression in breatliing — il becomes necessary 
to afibrd th^ conflnod blood meatLS of escape, by makicg; a suitable 
ui)eiang iu tie pariptcB. 

In tbo compiiiiiid fonu, the wound is kept open ; moans am takeD 
to arrest the blei^dino; at ita sonrce^ and at the same time lo afifiist the 
respiration; and inflammatory symptoms are timeously opposed. 

Pnmt m o- Thorax. 

Ttitt denotes accumulation of air in the pleural cavity. The case 
may be either medical or anrgiral ; the latter dependent on wonnd of 
the lim^ ; the former caused by perforating ulcer, connected with 
tubercular ahsceas. The traumatic form is the result of penetrating 
wound, oblique and valvular; or of fractnred rib, displaced, insvards. 
It haa also resnltcd from mere bruise of the chcet ; the lung and pleura 
pulmonalia having given way by rapture. Its mgna are : — abacnce of 
the respiratory murmur on the affocted side, with a peculiarly clfiai" 
resonance on perciibsiou ; the ribs nre fixed ; and, on tlje opposite side, 
refipiralion m puerile, as in the preceding atfeetion. la the medical 
form, there ia usually fluid as well as air in llie chest ; consequently 
a splashing of this fluid is hea^rd, on snccnssion ; and coughing pro- 
duces a ringing sound, termed metallic, or amphoric resonance. 

Trfatment oon^ists in Affording puae tit the working lung, and 
averting inflammation. Judicious loss of blood, aa already seen, eon- 
ducps powerfully to both objects, fa urgent cases, an outward escape 
is to bi^ aflbrded to the air, by acu-pancture, or by the thrust of a smaJl 
trocar and canula, 

Kniph^Bema souietimta co-exists with Pneunm-lhoriUi. It haa 
hoen already considared, incidentally. 




Paracenteait Thoraeu. 

Fimcture of the thoracic parietes may be required, we have eeen, 
on account of accumuUted iiir or bWd in the pleural cavity. It may 
also bo cailecl for in eonsfquonce of fluids huving eollected there- — the 
reaidt of inflammatory disease — HyJrothorax and Empyema ; afTectiooB 
which belong to the department of the Physician, and which it IB con- 
R*quently unnecessary lo con&ider hcre> in empyema the ride is 




312 PAEACBNTESIS THORACIS. 

fuund dull on percussion and swollen, a^id tlte nh& are QDOBiiall^ separatef 
thcro arc dyBpuroa, difficulty of lying on the aoinid Kide, and the other 
signs of pleural (H'cnmiiln-tion already noticed ; the aide enliirges mora 
and more ; fluctualior comes to be diBcemible id tte intercostal spaces; 
and ollimately, by ulceration s.t the moBt promiacnt part, spont&tieoDS 
evactmtion may take place, afi in ordinary abscess. 

For Ihc discharge of piiraleiit mid etro-pundeQt fluids, an opening 
is made by mctwB of a trocur and caiinla. TbiH uiAtmmouC may be 
employed, subin tegument ally, aa in tho cnht^ of cbronie abscess. Or 
the opening may be made direct^ and lefl patulons niid dependent. 
However made, the margiES of the ribs sboidd be carefully avoided — 
especially the lower — leet wound of the intercoBlal firteriea occur. 
Id the direct puncturef U is well to make an iucision through Lhe bkiu 
aud iQUBciikr atratum, by means of n scalpel ; merely comploting per- 
foration by the trocwr. Aa to the most eligible point for making such 
a wound, authorities greatly differ. The opening must be dependent, 
and sufficient in all reapecta for evacuation ; and yet it muBt not bo bo 
placed as to endanger tho diaphragm — though this muscle, it is to be 
remembered, is usually displaced downwarda very cuuaiderably by tte 
accumulation, and is further protected by the patient being directed to 
inspire during" the act of puncture. The space bplween the fifth and 
sixth ribs is frequently chogcn, midway between the spine and fctemum. 
Some prefer that between tho seventh and eighth ; others oparate 
between the sixth and seventh. Some go iia high as between the 
fourth and fifth ribs, having observed that naturiJ pointing not unfre- 
queiit!y takes place there. Of late, the spitce bet^Af-en tha sixth and 
seventh, or that between the seventh and eighth baa been opened, by 
cautious dissection and the thrust of a small trocar, at the moat depen- 
dent part — below the lower angle of the scapula. The patient ia 
placed with the aide prominent and dependent; and arrangements are 
made for turning him on his face, should oppresEed respiration ensua. 
In the tafio of direct opening, permftUEncy may seem preferable to 
clcjsure »nd re-optming ; and this is secured by suitable dreflsing of the 
wound. To favour discharge, the patient remains recumbent on the 
affected side. If closure be attempted, the greatest care must l>e taken 
to avoid the entrance of air; the patient is exhorted to shallow 
breathing; the canula is withdrawn before all the Quid has escaped ; 
and lhe wound is instantly shtit up. 

The physical signs of hydrotiionuc are not dissimilar from those of 
empyema. And often very marked benefit may bo derived from 
paracentesis- Accumulation having proceeded go far as greatly to 
embarrass breathing, the patient is arranged aa already described, and 
by means of a smalt trocar the senim is caulionaly withdrawn ; the 
utmost care lacing taken to prevent entrance of air into the pleural 
c&vity- Ejn^ugh having been removed, the puncture is treated so u 
to secure immediate union. Ami, subsequently, the operation may "be 



WODWDB DF THE BEABT. 



313 



repe»tcd| if neccsaary. Relief is certaiD, for tho lime ; and la not & 
few cftBos this adaptstion of surgery to medicine seems to have becD 
inBtnimcDtal towards a permamiit cure. 

Wounds of the Heart. 

Tliey generally prove fatal ; but are noL neceasftrily bo j and 
tberefore are umcnablc to ihe general principles of treatment formerly 
detailed. 



lTcnnen,MniUrT Surgery, Edin, 1820- Mayer^ Tnctatns de VnlneribuJi PertoTH,Jcc. 

BctdI, H23- Lnrrey. hlumoires Je Cliir, Mtlitoire, vol. u. and AlEinitir^j^ iLe I'Acal- Koyale 
dfl Mfdwinc, I'flriH, iflL'B- I>tf.l<>ng, Dim. di- VuUieribitB CcfdiaiGroning, 18118- GutliriB 
on Wutinclfl fln<l [njuric!? of the L'brac, LonrL IMS. Hlcherand^ No^g. Chtrurg, vol. It. 
p. fi Ttict. de.t S-^li^iiOES Mi?<l. vol. (v. ]i. 317r Dujiuytren, l^e^n* Oralea. vol. iL Cock, 
and HD|rh€9 on Para«ut«id ThonKiB, Gu/h Hospital RfporU, Second SerieSj No. lil. 
Luitd. 1844, 

In regard to Iryuri<-<of the Oieal^ much viUiiabli-iiir'mTUiitioa will be foandmGiilhrie'H 
CommenUry on tb« Surgery of tbe ^'ar^ Loiidcta, IB5G. 



314 



CHAPTER XXVI. 
AFFECTIONS OF THE MAilMA A^D MAMMILLA. 

Irritable Mamma. 

Tub female "brensl js noL imfreqiieiilly tlie soot of Irritation; giTing 
rise to much lucal uneasmess, nud tcEidiDg also to involve the system 
in BerioiiB disoriien Tht^ gUiid is nounse altered in structure ; sume- 
tiiaes thcrL> is slight puHiucss In the saperficial areokr tiamie. The 
pain 13 very cnnsitienible ; not constant, lialle to *?xftccrhfttions — ofton 
periodic — and otherwise eviDcing ihe ordiniiry charftctere pf neuralgia. 
Aggjavntion gtnemlly opeurs ot the looiiBtnud [*riod. The psilient 
is young or uf midille tige ; and nmally is pale, thin, and cachectic- 

Tiie affeclion is to be consiJercd as syniptouialic cjf niore serioua 
disease, fLod treated aecoTdingly. In the tuitjurity of cn^s, the ulents 
is to blame — disordered fither in structure or in function; and until 
this source of evil be rectiQed^ all other Ireatinent will prove of little 
avrtih la cftfioti of fonclion.il derangement, the prejiflrotions i>f iron 
am iniJicated- Oonium is of service in allayin* the general irritation 
of system. Locally, ihe cndcrraic use of nilriLte of silver, so as mereJy 
to blacken, often affords relief; and belladonna, aconite, and pnissic 
acid may be used in the form of ointment, linjuent, or plaster. Change 
of air, exercis**, attention to diet, and ihe oOier unlinary correctivea 
of chronic disenac, arc of great imjiortance- In Eome cases the symp- 
toms aeem dependent on neuromatous formation in the neiglilMUirhood 
of the gland ; and under such cLrciunatanccB^ corn may he readily 
effected l>y excision of the superficial tumour, 

Mammitis. 

1. v4ci/E^-— Acute inflammhlion in tbe mamma may result from 
exiemal injury, exposure to cold, or any of Che other ordinary exci tan ta j 
most commonly it is connected ^dth lactation. The pain and other 
local eigas are inlense; fever is proportionally severe; and suppuration 
is from ilie lirBt immiaenc. The secretion of iui]k xa Grst i>erverted, 
and then arroeted* Matter, when foriiicilj is seldom limitod to one 
part, pointing rapidly Ihore; hut rather tends to pervade the whole 



MAMUITIB. 



di6 



glan*!, pointing elnwlj; und the aljscPBs, after having become op^Rf is 

liable to dcgenurale iiitu iht conditiuii of siiiUH, 

In the outsetf leeches are applied in abnndauce, with hot fomen- 
Ifltlon; and the gland is carefully supported by a aofl handkerchief 
or shawl, paKsed beneath it ami round the neck. Small Joses of sul- 
phate of lUfLgneaia, in aciduWcd ^lution, lusiat antimony in atibJuing 
the febrile stale, and at tlie name time have ite salutary efi'ett of 
opposing determination of blood and consequent Lyper- secretion in 
the gland. When resolution ia to take place, this may be accelerated 
by gentle friction. MTicn matter haE formed, early evacuation should 
lie made; for thns nuly may future wverities by incision be pre- 
venleJ, In severe or neglected ca^ieej the gland maj be^ as it were, 
diBsecLtfd out bj the tuatter separating its coiopononl parts; or many 
sinuses may form, communicaliiig with each other, intersecting the 
whole mamma, and mised up with intercurrent abwesa. Such sinuses 
do not require to be eaoh incised throughout its whole extent — the 
knife following mercilessly on the probe; it is euougb to secure 
aalisfactory evacnitiuu by fluitable counter-opening, and then by 
prcBHUro to f^vonr coniraclion uf tho cavities. In thin we generally 
succeed ; and ^ontinuatice uf the pressure is further np^efiil, in pro- 
moting rileciiBsion of the mnrbid parenchyma in whicli the sinuses 
are placed. It may be applied by bandaging, by careful application 
of strips of adhesive plaiter, or by means of air or water contained in 
caentthouc tiJieue, els recommended by Mr, Amott. 

2. Chronic.. — The mumma is subject to enlorgcmcnt and induration, 
by reason of a slow, painless, and minor aninniil of the inflamniatory 
proceps. The whole gland may be affected, or only a part, Yowng 
adults are most liable^ The ewoiling ia more diffuse than any form 
of genuine tumour; and is Uttle painful, oven on manipulation; it 
feels as if composed of numeruuh small granules, and has the nega- 
tive character of wanting ibe local and eonslitutionul signa of carci- 
noma. Trefitment consisi.s, loeally, in light antiphlngiHticn, followed 
perseveringly by discutients ; con**titulionally, in attention to the 
general health, and to the nteriiie functions, by altt^raiivcs, tonics, &c. 

Oaladiirhaa, — By this term h imderslood a (ersistent and esces- 
sive 6€cretioa of milk; whereby emjiciation, debility, and even hectiu 
may be induced. To arrest and remove this condition, iodine given 
internally ftcems to poEsoM almost a sjieeific power; Buckling being of 
course desisted from, and the uterine functions restored. 




Chronic A I'scess, 

Chronic abrceGB is nut mifivqaontly fonrd of a eomcwhat peculiar 
character tn eonnfiion with IhiH gland ; consiating of a firm cystj con- 
taioing a email qiiautity of thick creamy -looking pus ; existing for 
months or years, and enlar^g slewly if at all ; situate sometimes in 




316 LACTBAL AND OTHER BWELLlNGfi- 

the glaai, more frequeotly beneath it ; firm, hecauso terse, to the 
touoh ; and somotimoB cIohcIj Eimtilulmg a Eolid tumotir. It may be 
treated either by enhiD tegumental or by Jireci piinciure ; or aQ error 
of diagnosis having been coiomitted, and a freo incisiou haviEg been 
made, the cyst may be dissected away — as if a tiuoour. 

Lacteal Tumour. 

One or more of tte kcUal tithes are liable to dislenEiorij by occlu- 
sion of their orifices ; giving rise to a sweMing analogous to ranula in 
its formation. The contents are milky during lactation ; at other 
times serous anl fluid, or caseous and solid — -oi partly so. The swell- 
ing has 9> flitctuatiiig feel, and extends, radiua like, frcm the nipple 
outwards; often it is of a eonical form, the apex towards the centre. 
Treatment ia by puncture, near the nipple ; keeping- the opening per- 
vious. Should inflammatory change take place, inducing obliteration, 
the occurrence need not be greatly deplored.* Sometimes abBCosa 
forms; requiring the ordinary treatment* 

Hypertrophy. 

The mamma is liable to hypertrophy, at tho period of puberty; 
usually with an imsatiefjtctory ciindition of the menstrual secretion. 
Somolimes a slate resembling nymphomania attends. The undue 
amount of development may usually be got nd of, hy attention to the 
general heiilthj nnJ to the uterine fnnctions— aided , if need be, locallj\ 
by gentk leeching, followed by discusaiven. Of these latter nune are 
so efiecttial, locally, ai^ pressure; and this is very conveniently applied 
by means of the hydrostatic apparatus of Dr. Arnott. 

Pendulous Breast. 

The pendulous breast is an afTection of advanced years ; httmg but 
an exaggeration of the ordinary diig-like conditinii wliich thia organ eo 
generally assumes^ in those who have borne children, and who habitu- 
ally neglect suppurt of (be part in dress. The only warrantable treat- 
ment is palliatiun hy suepension and eupport. 

Partial JIi/psrtrop?ii/. 

This is the " Chronic mammary tumour " of Cooper. A portion 
of the gland becomes hypertrophic d, with ultimate change of struc- 
ture — yet simple ; and etilargeuient of the lo\inles taken place usually 
from the onlword Burface, couBtituting a sr^ft unequal tumour. It is 

* I have known this BunpU morbid condition prove iLc prci^uraor of inveterate carci- 
Domii in the ^bnd. 



i 



VARIOUS TIHOCW OF THK VAVK^ 



317 



pecn^&r to the jonng adult, Bridaai if 
yesuB of ftge; UMi u alatait ahrs]« 
nUrine ej¥tea> Tretfneiit b tbe m» « Iv 
Marriaope, follow^ bj pregBUirj Aod BttdJin^i, 
successful means of cure. 

Tlie mmoor, though orig;iDaIl5 aoat n^l^ il 
tioD. CooM^iueDllr, wlmi ovdnwj Akwrtc 
JiHer due tn&l, it sbould be i^uded ■* otka 
to discnesion. "CotntDoo sak«« an UDed, 
geroua." 






pfVTVi ft 






The ^laad majr be Uie seal of Sit^te w^mmm, 

fin! b; diecuesioD ; utd, if tkAi £ul, by fF^kJun 

have a favonrite site Iier^. TtiMigb Itta lalife to 

any other morbid growth, tbej an cotaiolj bdI 

untoward occurrence ; and, tbe re fae , cxcapt ift tt« 9^0^ it s wifl 1 

remove li; operation ihat whiA on leiw pw bclkff Md mmf pv 

worse. Ct/itic sarcotna ia my cd^^mh. lAc ik* i 

tumour, it is moet frf^ueDt nodcr idmttf jean ^ ; 

chiefly among \\\e Vti^r clanea. TW V^tmm m 

of seroua cyets, the parenchyma mumJUiin^ of Itdr a 

stance of the glaud elightly alterevl kaik 

believe that these cysts may BMpctmus 
dilaUtiou. By puncturirjg the cyata^ and aftemrdj t^^tpa^ 1**^ 
tiare, the tatnour may diminish, «QDKilid&tft, u>d grbiainj ^MiffCMV 
in the minor coses. But when the whole gland li involrcd, i itii|ia 
Hon abouM be at once had recoarw to ; net only b«caiBe o<Imt trcaa- 
mcnt will prove iinBuccessfaJ, but because such tunioQii arc well kaovm 
to be peculiarly prune to degenerate, more eepei^ially vben uritated. 
Tmt liifdatids am also fouud in ihe gkud. When fiiugle, they may 
bs gut rid of by ptincturc. When niiTDcroiis, nblatlon of the put i» 
ex}ieilient. Tk^. MaHgnani tumours of the mamma are nnfortunatalj 
of proverbial frequency; more especially carcinoma. The generd 
description of this tnmour is not departed frotn ; the chief peculiarity 
being in the nipple, whichf early involved, h remarkably retracted aad 
fibriveUed in appearance. The glaiida <jf the axilla, too, are liable to 
be soon affected. The diflcaee is known hy tlie %'e of the patient, the 
hardnt'fs of the tumour, the charact^T of ihi? pain, the rate and mode 
of growth, the involvement of the tkin axvl retractimi of the nipple, 
the cachectic stale of the Eyatem ui eridtrfvoiad by tlie c^nitlenance and 
general appearance. The only cnf« m Ij 4e%t^ryUkjtt ; but it is only 
a small number, uf the many camm niiA f m imJO . ibcmaelvva to the 
siirgaoD, which varraitt operatioa ; mA it W0f k ntii Ui repeat here, 
that if the skin be much involvad, if dM aCf^ W MtitL retracted, if 
there be a marked depreadoa «vv«r dw ftMatwr^ if itm npen condition 



31S 



HALIQNAKT rUMOUllS OF THE UAUMA. 



be arrived ut, if there be AdhBHion of Lhe tumour to llie pecLorftl muBclc 
uT to tUti r'ihPf if tbere Lo omiauUB Bignn of sumo obsooro )'ot 6ori<>u» 



Vit-ni 








disorder pn>ceedingr within, and if there be glandular affection without 
— these, heing all sin^'ly tno&ii unfavourable, and betokening relapse, 

Fig. 117. CvcEDDinA nf the bremF, bisected- Tbr figure of th? tumour, with I ta effbot 
vn the t'^and and ni|Ji>le flhe*™. 

Fi^, llfl. Cnrriiiamii; BHuncInry. An pvamplo nf th^ numurktifl nodrtlplpH lumDon, 
wliich ofr<!D fcirm En the ticntrix of (lie former growth. One b nlcemtnl in tht site of 
iht innnmltla. 

tiff. IID, Fmigiu hieiUHtixlpii of mMnunn; fimj^l, blrfldiafp, uid hlood-Uhe, 





EXTIRPATION OP THE MAMUA. 



do moBt certainly, when commg together, contra-lnrlicate all ojierfltive 
inferference. 

Extirpation of the Mamma, 

The patient having- been placed recuraberit. and d\i\y anieslhetiaeJ, 
Uie arm on the afH-cted side is raii^ and held br an a^Elant, so as 
to stretch the pcctoralJH major, and fiLcilitatc incition. The knife u 
entered on the axillary aspect of the tumour, in a line with the mam- 
railli*, and ja uiovlmI \n a bcnij-dlii'lical direclioii towards the n|"|iUE*il« 
poiat ; a Eimilur prococdin^ in adopted — abi^vo or below, as tho oaac 
may be — to eomplote the ellipse ; and the size of thin hpw^e necefifiarilj 
varies, according to the extent to which the integiinjent eeoma to be 
involved, and according to the natural laxity of the parts. It is a fault 
to take a^ay an undue amount of sound texturea, so that diffit^ulty is 
experienced in eflecting and uiaiatahuiig nppoBiiioa of the wound \ hni 
it is a wofeo error to leave tainted parte, wLercby reproduction of the 
disease cannot fail speedily to eni^ue, It is well to make the lower 
incision first ; otherw-isje its cuurao and position are apt to be imcertaiB, 
uinier the irrigation of blood. Then, on each aspect, the knife is 
sloped through the subcutaneous fat ; and regular dissection is pro- 
ceeded with from the axilla downwards, dividing the principal vessels 
and nerves at once, and ao rendering the Biib&eqiient etcps of the opera- 
tion comparatively bl^xidless and free from pain. The dinoas^d uiafiK 
— with its border of apparently sound tiasuej in the case of mahguani 
tumour — having been removed, is carefully examined on every asj^ct 
by both sight and touch ; and, if neetl be, (he knife is ro-iipplied where 
thorough removal is not assuredly apparent. The vt'ssels having been 
secured, the wound is brought together, and treated in the ordinary 
way. 

Tamoura ewt€n\al to the mamma — forming in its immeiliate viciuity, 
but not incorporated with it — are not uncommon. The simple are 
removed ; leaving the gland undislurhed. In the ca*e of the avowedly 
malignant, the entire gland, as well as tht; tumour, is taken away. Of 
this clasa of tumours — oot in, but ocar the mamma — tho mBJority are 
simple and fibrous, 

A^ecihfia of the MavtitiiJia. 

Th^ mammSla of the male is Imhie to hypertrophy and to malig- 

^^ nant disease. In the one case discnssivcs are expedient ; the other 

^^fe demands free and early ablation. 

^^H The nipple of thf* f'CTnale is alao liable lo hypertrophy, und malig- 

^H nant disease. In the former case no direct interference is reipired; 

^^ in the other, there is safety in nothing short of sumniiiry removal — not 

I only of the nipple itself, btit of the mamrua also. There h one case, 

F however, in which it is unnccetsary to nacrilice more than tbe Fornier; 

^^^ — when the nipple has been hyperlruphied many years, and begins lu 



I 




320 



AFFECTIONS OF THE MAMMILLA- 



rlegenemle in strudure. Sucli dc^nemtion usimlly commences in, 
and IB at first limited to, tlie apex ; and, in such a case, to cut at Ite 
root of tlie nipple is to cut in Bonnd ^mrts. 

The fissured and excoriated nipple of tbe nurse ts an affection aa 
frequent as disiresslng. A bare enumeratit>n of alleged cures would 
occupy miicli HpHce. Siiffico it here to sjiy that ikc fiume trcn-imcat is 
necsBBftry bb in inflftmed and irritflble sores, modified by regard to tte 
Ufies of the part. During application of the child, the nipple is pn»- 
teclcd by a ehiidd ; and in Ibc interral some of the many remedies are 
applied, n-bieh are not likely to iojure the cbild, while at the same 
time they tend to soothe and heal tbe afTectod part. 

Alxmi^tby on Tumouis, Load^ iSiU. Cumin, a General Viev of DiseasE^ of the 
JUamiua, &c., Edln. Metl. and 5utg, Jifuraal, vol. xxiiL art. 1, IKT?. Cooper, Illua- 
trationi of Di«;JWM of ih*" Brea-*t, Lnnil. IB20, JeimMlmp, Mtuncirv stir Ich InOiininu^ 
tioiu cC k<» nhsc^s till poLn i^hi^^ In fcmniep Gilz^Uo MGdu-Alc, Jon. lS3ft, C. Bdl oq 
CoiL-iii^jma Alumui^f Mvd. Cliir. Tmn». ti>I, xlj. p. 713. BradJe, Leaurrs on Pathdlugy 
And Surgory, Lond. 1S4Q. IJirk^-ii ^»n Diticoaee uf ibo Bj-finat, Load. 1860^ For^f; Bul- 
Itftin dft Uteiapeutique, torn, xxvii. p. ^&b. 



321 



CHAPTER XXVII, 

AFFKCTiONS OF THE A31DUMEN, 
Abscess of the Abdominai Farictes. 

AascE^a of the abdomui^l pAriGloa RomGtimes occurs BpontHnooiiely ; 
frequently, it Is the result of external injury; ami, in some RyFtemB, 
but ft slight Llo^ — or a striin^ na in relciiin^j — miiv aufliee. 'Die mlo 
of the ulscesa is more frequijntly deep-seated iban superficial. At first 
ihere ia a hard, tender, incraaeing tQinoitr, ivliiclj eufii^is Dbscurely hs it 
eiUar^ti, aud slo\\ly potiits, Tre;itmeut vmit^ acoorJijjy' lo lliu stiigu. 
At firBtf wliilo tbo indnmmiLtory prooogh i^ but rtc^ent und filigbt, and 
the swelling- cfin-slsla of [dastic exiKliLlion^ resolution is in our power, 
by rest and iintipbloj^ties. Advancement of tbe turauur is arrcsteJ, 
and tbo bard swelling liegina to disappear. Tbifi subsidence miiy be 
accelerated by judiciously used discus^ives — employed, buwever, always 
witb the f^eate&L cauUoii, iiiaamoeii as we know by e-\(ieriL'UCL- tliat if 
they be used dlber too frwily or too booh, there is hero « great pro- 
bability of inflammatory reaccpssion, in an aggravated form. So sooji 
as the formation of matter has been at all indicated, a free evacuatin;^ 
incision should not for au instant be delayed; it bt^ing iximemliered 
that the pus is much nearer to the peritoueum than to the inte^^ument, 
and moreover bound do^vii by slrativ of dense fibrous tissue. But it ir* 
auroly itJvibiiblu to go a Htojj fuitlier \ aud wbcacvcr wc feel conviuctd 
that reasouable hupe of arrest aud reB""ili:lifm is gone, make an incision 
in the most prominent part of the swellin;^, where we anticipate that 
mutter is iirat and maioly to foriu. In order that so soon as it doea 
form it may find a ready drain for its outward e5Ca()c ; all the hasardB 
of its peiil up aceuundalion, in any quutititTT bcduif ihc-rtby lelioitously 
ttvoidiid. If ttruficjul o[ieuing bo witbiicld, ooo ef two ev«nlB ia very 
liltely to occur ; the pus, finding its way into tbe general ejtvity of the 
abdomcUf excites a most hazardous pmtomlis; or, on spontaaeoua 
evacuation taking pkce, the condltioa of frecal fistula is declared — the 
perforation internally, surrounded by plastic exudation, having pene-* 
tniied into an adhereut fold of intt^siine. 

A» already atuted, eherry f^tones, aud such like sub^tancei^, m&y ho 
arrested in the vermiform proeesa of the crcL'um^ and eauso abscesS 
of the ubdominal parietes; so effecting their own escape. 

y 



322 



BRUtSE 0¥ TUE ABDOMEN, 



Tumours of the Ahthminol Pan'eteB. 

These demaiul alw early attention, lost, hy Ictig coiilinuftnce ami 
enlargement, Ihey l;i*conie imfavonrably connected with tlie deepest 
portion of the purietnl latere. The adipose ir, perhaps, more comtnon 
than any other form of tumour in this sitnatiou. Id dissccKng it out, 
tba preliminary inciBiona should penetrate quite mtt; the KiibKiance of 
the fatty mutter; thereby faulli tuning extnictiun, and avoiding uane- 
cessory depth and extent of incision. 

Brtaae of die AMomen. 

Thia 18 always imporUnt; on account of risk of injury to tbe 
abdomiriiil coutents. Dangeroua hemorrbage luiiy at onuc occur by 
leflion of those, or formiduble inflammatory disease may bo kindled 
subsequently. And, in Ireatment, both of these contingencies mast he 
regnrded- Absohite reel and (]uiclnde are enjoined ; and the simplest 
ingesta nre givpn most sparinn^Iy. Thus, extravasation of blood from 
atom jwrt Is not favoin-ed ; neither ia escape of conlenls from any 
ruptured virii:ua pruiuoted— on tbe contrary. On tlie firKt liaing of 
tbe piJeo beyond lhe limitR of modorato reaction, on tho accoBBion of 
increased pnin, with vomiting or olher sign nf rlisorder of the pystem — 
in other words, so soon as there is any indication of the inflammatory 
procejis having beg^m — the lancet is employed freely, and is followed 
by calomel and opium, as circiimsjanccs may demand. And hero the 
opium may l)c administered in a larger proportion than usual ; it being 
the only avuilablc opponent of the intense and oxhauating pain nhicb 
atl^nda on sueh disease ; and it besides being of good service, in injury 
of tbe intestineK more espei-'ially, by exerting a sedative effect on the 
mascnloj coat of the bowela. Very obviouBly, purging is not to be 
dreamt of, in the early treatment. Snbeeqtienlly, when it ia necessary 
to move lhe bowels, the gentlest remedies are to bo selected ; and 
even they arc used with cantiou. 

The first effect of bmise, attended with serious injury of tbe in- 
ternal organs, ia to produce a marked elate of bhock, or depresfiion, 
in the eysteui. And a very common error in practice is, at once to 
attempt removal of this. The aame evil consequences follow, as ia 
the auabgxjuB casa of injury done to the cranial contents- Let tbe 
patient blone ; and ere reaction occurB, with ita quickened and 1il11 
circulation, a torn liver or spleen may have hnJ its vesseU closed 
by Nature's hemottalics, and a nipttircd portion of intestine may be bo 
circumHtanced by [>osition and exudation, as tu render fatal escape of 
its contents into the peritoneal cavity at least less probable. Bnl, 
etimnlale unwieely; and then premature reaction is estahllshf d ; the 
retnrning blood finds the mouths of veesels still open, and intestinal 
uxtravftRalioR U qinte unopposed. In one case, only, are wo to int^r- 



L 



WOUKDS OF THE ABDOMENh 323 

fere ; ftiid tbut la^ when ibe ebock ia cxtremo in botb iDtefidty and 
duration, and threat«iiB to prove directly f&tal. Tlieo we nljmulate, 
to BRve Hfe from immediflte loss ; und yet wo siimnlnte v<?ry oautioualy, 
leal Bavint; fram ono ha^aril wa engender anolher at least as great. 

A wmoto consequeEice of abdominal bniisc may be snch atropby 
of the miiflclea at tiie injured part oa shall cause pennanent weakness 
there, with consequent liability to hernial proirnsion.* 

WountU of Uk Abdoinfjf* 

Wounds peDctratmg tbe abdominal panettK, and implicating the 
viscera within, are necessarily fraught \ulh much danger. From 
lesion of tbe liver, a formidable hemorrhage can hardly fail to occur ; 
wound of the nrimtry bladder cfluaes lEfiltration of thu conttiite, 
almoflt invariably futal 5 from wound of the gall -bladder, acrid bile 
will eflcape^ kindling intense perilonitis ; both acrid exlmvjisiiliou and 
dangerous loss of hloiiJ are likely to fallow woimd of the kidneys; 
wounrls nf the spiet^n, iike those of the liver, are dajigeroue mainly 
on account of the risk of heraorrhas;e ; fnun injured intestines, hccal 
eiitravH&ition ia likely Eo take place, catislng an extcat and amouat 
of inflatnmation whicb ia seldom if ever recovered from. Such severe 
injuries arc invariably attended with a grave amnnnt of shock, which 
flcrvea the double purpose of warning the atlendnnl of the importance 
of the case, and giving- an opjtortuiiity for the cumpleliDn of Nature's 
measureB for obviating hemorrhage and esiravasation. This stale, as 
formerly observijd, jh nut to be nujhly inierfereil with by the [prac- 
titioner ; its progrcGH ia watched; reactioo 13 rather dolayod than 
bfLirtened; and when this, no longer repressihle, advances to ejceas, 
arjtipldoj^ticfi are eniployed actively. 

Wound of the Bmoei — Huspectcd when discharge of blood by the 
moutti or by the anus accompanies the attendant shock — is nnt neces- 
Harily f'dloffed by eilravasalhm, A uh-vg puncture is closed by 
Nature's cfiurta. The mucoua coat is protruded outwardo, and plugs 
the orifice ; the nMominal viscera pxert a constant equable [treasure 
on each other at every point, and this tends obviously to counteract 
escape of contents ; and these two temjiorary means of arrest are duly 
followed by another which is permanent — TjamLdy, exudation of plastic 
lymph eu the exterior of the wound, whereby union of the op^iosed 
HUrfai-oa of peritoneum, and a aafo circumvallotion of tho JnjfLrcd part, 
are effected. As in natural hemoMtalics, llie temporary means are by 
plug and pressure, tho permanent by plastic exudation. A moment's 
consideration of the nature of this process will explain how nDiachievoaB 
must bo the impnident exhibition of stimuli, or indeed of ingestaof any 
kmd, at the outset of the case. 

Protruiion of the D'>wA, — If through a pcootrating parietal wound 

- QL-^JiB[BtLllJ1lsL,^'a. t441,p.a&T- 



su 



wacioie or the addouk^. 



h |KtHLoEi of inteELiQc, or otli^rr viBcus, protrtidffi entire^ it ie to lit 
iimply repln&'il ; m itli all ^enlloness, sii as tii>t to endmtiger an a^jgrm- 
Tiitioii of iiitiunitoatory ot^etssum ; and yet irilh all accuracy — tW 
Gn^er following the retreating vibcue clr^selr. eo aa to eitsare its Mi^ 
rei'laceJ wholly \iiihin the abdominal cflntr, and llias avoiding tb« 
ft^rioim risk of oliK^urc i^lnui^lnliorj, wlilch is eo prone lo follow partial 
riidiiclii-n. Tbo wonnil is cafvfiillv ftpproximated — fey fiijtiir?, if aecj 
b<^ ; and Ly mod^^i'nre handing euch prE'tcitre is made ibitliout, a» h 
cak-nlaied to prevent rt- [troini^ioD. In ^^ibeequcnt ireatineiit an umom 
jTopbylaxia i^maiiilained, i^Ith aprep^iiaUon for Guittbte aalipblo^iiEtks 
on tiie Bhorlt'st notice. 

If the protruded pari be found to have Buslviined mere pwncitire, H 
TDtt)- b« simply rt'pUctd, as if intact; tnisting lo Kjiiiii«*e mtan» gf 
cloAure. [f n InrgLT vonnd exist— incis*^, of no gr&ai extent, *i^ 
couneqiieiitly deemed capable of adhesion — it 
is to bjT bronghl acctirat<?ly logieiher by the 

r glovers' tiutore. And, in ippSying- lliifi, it i> 
ne]\ to turn in the ecigefi oi the wotindeil 
pirL gently, so thnl the approximated s^urlac^ 
sliaH bf |KTritonc-al ; ihat Blmcture being wcH 
kiio;vri to he mncli more capable of ihc 
rt^uired pljwtic csiidaiion, thj^n are Ibc mn- 
CUU8 or middle coals of the bowel. The punc- 
tures of the Deedlc felnmld nut be more than a 
Ijiii; apart ; aod the fingei'^ of an as^i^itAnt 
should accurately rvtahi the inverted con- 
diliou of the wound dufiiig the manipnlalion. 
^ *'? *** It is well lo lake the first slilch from within 

otilnanitj; aud ihc placing of a larg^ knot here is EUpi-osed lo favour 
the inwanl c^npt^ of the tLremt ; wliich iii time ukenites its way into 
the ravicy of ihe bowtd, and h thence diftcbaj^gtd. The Bitfure having 
tm'ii duly iuraiigwl, the \tnTl is gently replaced ; in tht- hope iLni it 
iMAv b^MMUit* Kufcly cov^re^l iiji hy ]>la£tic exudation. 

If ihe iiTtiim L>f iHJWel be Lmised, or ulhenrise so extensively 
iigumi as I*' n*i"irr the oornrretictr of adLesion obviously impoasibli^J 
il irvtv fidly ii> I'flect mechanical union and replacement of ttie parL.1 
Aftrr auch |u\K>Hhire, the wound muai necessarily inflame and open,] 
ffts'iilnvl r>1ra\.^vs«Tiv<n 10 inovii^ible, and death is almoGt certain. TboJ 
uohttvlol \\nti should Im rrtiiitiecf n( ihp surface ; and, n'ith this view, t 
tlu' t^^rilouenl ov^t it^ muled with ihe inlegument, at tlie lip of the 
«o»ind, at \\iw tu nu'n.' iK^ints by siuure ; and then through the upper 
iHitiiV itf till* w^iumkii I'arl the fa-cu3em contents discharge thtmi^elves 
iiUKH-UtiiKlv. Tlir nitnclilioii of .-tr/i/frnif .4m/-} is established; a state 
lif UkMvb diK'iMiifitrV, aitd not altogttliur devoid Ljf doii^r ; but infinitely 



ti|t. lAk lli*||lAi«n', 14 tvntlhutj aiMiirvi Ih nnUHt ofthB b&nL 



I 



ABTIFIOIAL ANr». 325 

prerc-ruLlo 1o fnUl pGrltomtiH by fieculcnt oGcnpfl wUliIn (ho OAVity of 

Thus, tlie local treatment difFers acconiinrj to the Daturc of eitch cas«. 
lijit in iili, ihe constitutional creatmeDt is tte ssime ; rest mid *|iiietu<le ; 
starvation ; free vcfiest'clion or leecliing^ or both, on llio lirsl onset of 
tlie inflivjiimaUjry prucessj tlieti calomel and o^Jiinn — LLu latter in 
largo diise& 

Artificial Anm. 

By this term is meant an imtiatural iiutward opening of the intestinal 
canal, whence fjecal contents are more or less copiously discharged. It 
way be the result of wonnd, of abscess and nlceriition, or of Bloughing 
ooiiscqucnt on BlriLn^nlated hemia. By [iliwlic exndjilion Ihe open 
portion ufbowel in rvtained in conhiet willi [lip alKlominnl piLi"ii?teH ; anil 
the following' amdit ion of imrts becomes estublished. The orifice oftlit^ 
upper or gastric jHJrtion remains iibundantly palenl, and not nnfre- 
quently troublesome prolapsus of its lining memlrane i>ccurs; the 
orifice of the lo^^'er or rectal portion couirai;ta, is not patulous, and 
rcc!?<]pB from the external Biii-facc ; Ihe tuo portions Lave a deuae 
septum interposed betweon them — coin|iosed rnninly of the luo eon- 
tiguous pnrlioneof the cnata of tlie bowel ; and Iliia liecomea raoro and 
more Bclid, and more and more oppOKOd to restoration of the normal 
flow of the intestinal contents. Outwardly the abdominal paneles 
are iiwually distended into a fun nol- ah aped cavity, whose apex is at the 
integument, who&o base purronnds the inlesLinal breathy and wtlbiu 
whosie cnviry fji?ciileiit manor tyiids to accnmuliitc. Tlif^ integiitneolal 
opening ra red, everted, prominent, and surrounded by excoriation. 

Tlip dangers and dillicuUiea of su'di cjisea depend very much on (ho 
aite and extent of the intestinal oi»euing-. If tUia be large and nesir the 
npper part of the tube, death by inanition can Ecarcclj fml to occur ; 
chyle running ho muoh to waster, Ifj on the contrary, the oj^ning bo 
in tho krgo bowf?lj milrition may be Fiiflioiently rDaintained, and ibe 
result will probably ]tc one more of Jinnoyance than of danger. 

Treatment ia in the first instance ;udliative. Such food is taten 
UB is easil>- digested ; and the bowels, by diet, and medicine, if need 
be, are kept ''soft and easy/' By external support — by compress and 
bandage, or by tlie adaptjdioii of a buitaLle tmtiH — outwiird eflcapc from 
tho npper orifice is modfi'ited^ if not nUogolber prevented, and pfo- 
trusion of the mucons membrane is opposed. And the ordinary mem* 
are employed, to obviate escifriation nf the surrounding ini«^ment. 
The outer opening may contract and beal, the funnel -abape'l c«vily 
may cU«e, and Il:e normal liow may be restored. Bui much nnHv 
£requeiidy such iB not ihc case i and furllier intcrftreooe by war »rt b 
reqTiired. The two main obslaolea to cure plainly mre — projection of 
the Replum, and retraction and contraction of ibc lower inteetlnal 
orifice. The latter state is to be opixised by tbe occMooa! inirodticiioo 




of Ito 



kllog lliMt prawine «> tfctf iktm^^^atarjjmtittmit* 
go bcTotd alccrmtion id the |Bft, ear gylg^d thcaee t* tke j 
Icxtarv*— bjr *fil*>><>€ a&d I m giag fagwirf tfce [ 
■uinb^dog the extmal picMBm U iJl ti ta ^ W alfal 
■re not ID qm, ve bope to rerton tihe i 
ni&n«Dt cloaore of tbe qwftare. BU nol <Aly mm^ lUt sm 
fifrceps be c«atJou«I; coodncted ; H mntf aJao W wttdlj 
We«kA or even montiiB sbuold elapov befen ii im i ■lyfcijiwL Foti *■ 
w\y appTJcatioD u plunlj in &Toar of the oc wir rtocp of ^ Hhwiin, 
jiiks ; A f^Ad of bawd interpoAed betwe^ the two orifices on ao c o m i 
or the septum Dot betn^ yet fully developed, tii«j be g imi e d bj llw 
ifutnirnpnt, and Uxa\ epEeritis may ensue; or the jet recmt, toAr, 
ftitd Imperfecl adbefliona of tht howtX to tbe paHetn oiaj be InAe 
Qji, the former may recede, fieoiileDt eitrav-isatiim tli«i> tiJkEcs pJj 
uid life is soon ended miserably by peritonitis; or, ftmply on sroDcint ' 
of tbe fltill unqoiet puts Wvlng do toleruic« of a oevrly excited ia- 
flbtpmatory |in>cesa, icumatcre um ot the forceps may be epeedfly &tJ 
loneJ by enU'tilis; or the prcranre may cause ukeralion of an ; 
kind — ]ji>t iaieutkil by plaAltu e^tadalion aroupd — the abdomioal cav^ 
iiiuy co]iKef|ucQtly l^cumc exposed, and fa^nlent extraTBeatioQ m^j 
occur tb^rein. 

The projecting wptum, or fprron, may be repressed amply l^ tli©, 
pressure of tentd; or the isgenioiiH, though somewhst complicated 1 
instrument of Mr. TraiU' may be used instead of tbat of Dnpnytreo> 
Such presHure^ caiisiiig rtplacement and abhorption of the prxyecting 
obstaokf i* obvioiibly raoro safe tbao that wbich pnxluces dealnictivo 
ulcemtion. 

An artificial anus is BomeliineB CHtablished, designedly, by ih%i 
Btirgeoo; when tlie natural anus is imperforate; or when, from anyj 
o.-niae, the reclnm has become insiipeiably obsinictedp These pru-i 
i*eedings will be conadered, in connection with affections of the lover ' 



* DuUinU«LIVr«,voLkiu.r>.306;uidBHLaiidFor.Me<J.Chir.BfT.Ju].]a47,p.3& 



PELVIC ABSCESS. 327 

Farc^l FiiftuUi. 

Wbeii au artifi<;iftl auua has coiiliiiL'U'd to a narrow amiij*, witli a 
IMLpillary orifice llirough which int^Hlinal coDtenls occaaionally eficajw, 
il is termed a Frocal Flatula- 

A eimilar Hliile may also result from pariGtal nlwcosa; whose cavity 
has opened, by ulciTation, Into a portion of adlit-rent howd, eitber 
before i>r after estenial cvHcuation, The oj^etiiD^ of communication 
is Q.sually email ; the cavity of the alsccBs tontracta ; arid tbe conditioji 
of fistuh is eoon cstahli^hed. 

The methodHof Erttttmi:;ijL art fciiuple. Accurate ami tirm preiisure 
IB applisd to the part, ho as to prevent fiecDletil e^eitpe, nod fb-voxir 
consolidation of the entire track. This may succeed, after patient 
cuntinuance for Bome time, doDg* wilh due attention lu the state of the 
bowtle. If it fail, then tbe actual cantery may be applied^ so as by 
cenlraction of llie bum to obtain closure. And if lliis do not succeed, 
liien hy auloplasly tiie chjisai may be filM up mid ^HJiinaneutly cou- 
solidAted ; a suitable [>ortLon of intugument being traiitplanted from a 
neighljoiiring part, 

Pefvic AUctM. 

The sub- peritoneal areahir tiiisiie, in the pelvic region, is liable li> 
be tlic ftcal of suppurative inHaiauiatory <liseaae j soujctituts in cun- 
neiioii with tlie puerperal atote, but ofL«n wholly inde[>endent of this. 
Occasionally it is induced, ou tlie rigbt wde, by irritation extended 
from the caput ctccum — forming the peritj/phlitis nf Bunifi and oLliera ; 
oil the left sidt iL may originate in impactimi or otlier Hisorder of tbe 
lower Ifowel, U hati followed operative interference with the uterus 
or itfi appcrdiig^is— as well as with tbe pL'uia and bhiddi^r — not uufre- 
queotly i Kometimee it is traced by the patient to a ehjll \ Koraetimet 
it can be connected with no aBsi<,'nablQ cause. The diseui^ \b more 
frequent in the female than In tho male. Exudation may be both 
rapid and copious ; and at first ts either Berous or lymphoiis. In (hi^ 
Btate it is amenable to ahaorpdon ; aad under EuitAlile treatment may 
diuapiiear rapidly. Wheu suppuiatiou has f^iirly takett place, cvacuA- 
tiou is to ho looked for, oitbor BpontaneouBly or by the hand of the 
Burgeon. In the former ca.se the point of exit varies; at the bypogas- 
trium, by }>ainting in the ordinary way ; in the grcun, by the bowel, 
ihrouirh the vagina, into the bladder* or into the general abdomiual 
carity. Fortunately^ the last mentioned casually is comparalively rare ; 
the |jeriloneunj^ &om its fibrous natiui;, lony retsitsliu^ the ulcerative 
tenJoncy of the accamuktiug pi;s, SoTnetime^ instead of eiippurnting, 
the tissui? hecomeu loaded with a dense plasma, partially incorporated 
and organized. 

The symptoms are often ushered in by rigor. There are pain and 
tenderness of the part, witli tbilness on [>crcusHion. Tbe rectum and 




HSTllO-OTEEl^E SAKOUINEOUS TUMOUItB. 




VlftJder, being com pressed, and inrolycd in ayrnpatliy, Lave their func- 
tions more or l<?ss distiirlii-il ] mul tiip uti^nw^ too, is liable tn diajilaep- 
menl. On osamiQiTi<r by the viLgiiin or ret;tniii, o bard dense swelHn^ 
is perceived ; determined to be nou-uterine, if n<?ed be, by Ibe use of 
the probe ; mid, unlike otber peine tumonre, having very firm cim- 
nesIoTi und conlinnily wiih the bony walla of ihe iielvis. In doubt, 
an exploratory thnist mny bo made bj the Btnall trocar — through the 
ftbdoniinal paHetes, by llie vngitia^ or bj the rectum, according as the 
site of the swi^Uins: may determine. On oiitward pointing taking 
place, the nature of the case becomea abundantly plain. 

At an early peri<:KJ, the treatment consists of leeching, fullowed by 
cotinter-iiriiailiin^ nod mercury pushed to ptyalism. Iodine may he 
painted over the abdominal piir;ct*a ; or it may be administered in the 
form of ointment, by the vngiait. Under such trefttraent, with rest, 
and attention to the generd hcidlh, many formiJable cITnaionH E^itis- 
factoril y diBjLppear ; [lerhapfl leading an inex^x-rionced observer to eup- 
poBe rhai an ovarian or other tumour has been discussed. When mailer 
has formed^ it should be early evacuateil, by means of the biaiotuy or 
trocar, ^t tikc point ^hidi circnmRtances may indicate us moFit Ftuitablc; 
by the vagina, by the rtclum, or thrmigh llie abdominal walls. 



Rctro-ut^-rine Sanguintous Tumours. 



There va auolLer clasa of ewellings bi tLia sittiaiion, which may be 
miKtakon for Iho intlamniatory polvio tumour, in tlio female. They arc 
caused by extravasalion of hluwl f^to the pnb-peritoneal arpolar tifisiie 
of the cul (!'• s(\c behveen the uUrus and rectum ; and in their patho- 
lo^ reeeniirle ihe ihrombus, xihitdi la not uufreqnenLly found situated 
in the vagina or vulva. The ail'eclion may, in tk-t, bo dewiribed aB a 
ibrouihujj of t\\G ruof uf the vaginn. Atli^niion hna betjj rx-cundy 
directed to ihie Bubject by some la(o diseiissiniip in ihc Kur^cal Society 
of Paris 1 and Dr. Moritjjomery of Dublin ha*j published taBcs of throm- 
bns ill tliia siLuatiun, occiUTing durinj^ or afler labourn 

The bloi^d is inliltraled into ibe areolar liesiie, around Ihe cervix 
uteri, and may spread tlieuce into Ihe areolar lit^uo (lurrotinding the 
reulum, or mtu that involved bttwecu the ftil Js of Ihc broad ligamenta. 
These timioiiPK me liable to tictur t'hit'tly in cast's whore there is luiich 
venous congestion, and esiiecially if thtre ia a varicose and diseased 
oondition of the vessels. They ai'e caused by powerful atrajninfr eflbrta, 
HB in labour, venereiil excesses, &c. They may also, as M. Uiiguier 
points out, be pro*iueed by the escape of blood from a uicnis over dis- 
teuiled by retained menstnLal seeretioun 

On e\aminalioii, the roof of iho vagina will proEont a bard reeieU 
ing surface, wilhnni [uuu on pn^w^nre ; or, if receni, tender to the (onch 
In It much Icbs degree than llie real inflammatory peJvic tumour* The 





OVARIAN DROPSY ANT> TUMOURS, 



•62^ 



ut^ruB will be fonod generally samewhat elevated, and pressed to i!ie 
puljca. 

If thi?y nre rihilII, these (umoun* require no spefia.] IreiLtment. 
Rest in iho recmnbent ixjBitioti, and the antiplilogislic regimen, are 
necessary as precautionary measures. If the estravaaatiiin is very ex- 
tensive, there will be constitutional distiirbatice ; and local excitement 
may be produced, perLups tcrniiniklLn^^ m Lrae infljimmation. In thiH 
case treatment must Lc condnctcd oa in the common in£ammatory 
pelvic tumour, 

Oearian Dropsy and Ttimours. 

Of abdominal tumours, the ovari&n are those which most attract 
the attention of ibe Burgeon. Occasinnally fibrona tumours, or masses 
of tbu dilTeront forms of tlio ordin&ry malignant tiimniir, arc found 
afFecLing tbe ovsiry, either alone or in eoinbi nation with the cystic 
dieeasii of tho organ — which latter very fur surpasses al! others in 
the frequency i»f lis occurrence, and is generally known as ovarian 
dropsi/. These cystic tutnonrH are mnltilncular more frequently tbau 
m^nolociilar. They may occur only on one side, or oti both at the 
same time ; they moy bo attached by a nnrro'F pcdicl<j to tbo broad 
ligament, rtr by a hroad haa« ; they may he movable, or fi:ted in thi* 
cavity of the ahduraen — this generally depending on thtir fiizc, which 
varies extremely ; they may bp fret-, or more or less adherent to the 
snrrouniling organs, or conneeteil with the abdominal walls. On 
disBcclion Ibe ovary of the afle^^ted side may be undiacoverable ; or it 
may he cither entire, or partly incorpi-naled with the tumour. The 
dieeaHO is believed by nTimorons pathnlogislfl alwnys to originate in the 
Graafian vesicles ; and there is good reason U> ntlnbuto certain of 
these preducliona to this sonree; but it in eipially well ascertained 
that the muUilocular formation does not always acknowledge sncb 
an origin. 

The disease may affect a womiin at any time of her tnoiistmal lift, 
and is found occurring most frerjnentJy at that [>eriod when iht repro- 
ductive functions nre in grealewt activity — namely, lietweea the ages 
of twenty and forty. It attacks the virgin as well aa the married 
woman. Of cijurae it is ionnd more freqnertly m married ihan in 
nnmarried womi-n, bni there is no c^Hdence for a common statement of 
Kuthum that the former arc more liable to it than the latter. 

Many causes tonaecLe".! with menstrualion, marriage, and parturi- 
tion, have liecn as,signed to ovarian dropsy, hut this ]^art of ihe [n^tory 
tuf the disea&e is necessiirily very diflieull of investigation, Thew affec- 
tions may be mere precedents, and not cimses. 
The disease may atlaiif a large dovflopment, without giving rise 
to any pymptoinft except eiich as are rcftrrihlu to die di^plllccmenL?* 
eflVeted by itR hulk. It may bo accorapaoieJ by irreg»darity of the 
menslnul function, by iBetiorrhugia, or by amenorrhmn. At itw com- 




330 



OVARIAN DROPSY AWD TPMOUItS. 




Eueijoemuut there tao.y bo mticli coinplmnt uT pain fmil luadcmcfiB in 
either siilo, or a Heyp-seuleJ i>elvic jiaiti nmv MiBt, or there may he 
other modifications of pain and t^Ddeniesa too varied to doniand de- 
acriptioiL Tbe tumoar maj press on th« eacral nerreH, and cause 
ntimhneBS nnd a feeling of poworlessnese in one limb; or \enous oon- 
gestion and a?dema of it, hy obstrucling tlie circulation, Thnre may 
be pflin jLnd difficulty lu defu^calioii. Piles, nnd a vancose ntate c<f the 
veins oF thn Ipga, are often found. In cliagiioniH, onr reliance mtist ho 
placed almost entirely on tlie physical Higns. Much obscnrily is ofteii 
produce*! hy distention of the nbdoracn, with fliitnlfnce, when the dis- 
ease is in an early slagc ; and the evidence of its nature is derived 
chiefly from the circumstances of its iMJsiiion, its mobility, or its con- 
nesiona. At a Inter petiod, wlicn it in distending* the abdominal walk, 
we tniBt to its own phyBical cliaraclors, the natnre of it* contenta, nad 
tbe history of its (iri^^n and progrces, 

Carefnl manipnlation uKually shows the swelling not to l)e so 
uniform ov Kift as in uKcites^ hut more or less broken up in its outline, 
as well as of varions hardness. Attention is also given to the follow- 
ing pointa 1 — Td ftscites, the fluid always occnjiiea the moat depcndeat 
ports, wliile tho sxuall intestinos, floated by their containi>d air, corres- 
pond generally to the umbilical re^'ion ; and tbe arch of the colon and 
tbe smmacb occupy tbe epigastrium. Fercnssinii, tberefore, eliciis a dull 
sound over the hypogahtric and lumbar regions, and a clear one in the 
umbUical and gastric; whereas, Id a largo encysitd dropsy, no lympa* 
nitic sound tisiats iu ihese ru^ons. The inteetines, pushtd back by ihe 
cyst which is dGveb"n>tfd anteriorly, may, howeTer, prwiiiee a resonance 
laterally and posteriorly. Fluctuation is generally more easily and dis- 
tinctly detected in astitea. If the ovarian fluid is of great i/isddity, or 
if the anterior cysts of the mass arc numerous and small, fluctuation 
may Iw scarcely perceptible ; while, on the other Land, if tbe disease 
bo monulocular, flnetuadon ntay be very appari-nt. SuULetimctt, in 
tha multilocuJar variety, the larger cyats can be made out separately 
by the facility and ^lishnctneas of the fluctuation^ when both banda 
are over the eama cyst; and by its indistinctness or absence when 
one hand is on one cyst, and the other on a different one. In encysted 
dropsy, tbe general bealth is often comparatively undisturbed, while 
in ascites tlie reverse is alm<'st always found lobe the cajje. iUong 
with aaeitcB, there is ^iierally anasarca of the lower extrenjities, 
wbile in ovarian dropsy rhifl is rarely obeer^'ed. In tie latter affection, 
however, we frequently find a varicose slate of the vessels, and iiuffi- 
nesH of the limhp. It is also to be remembered that asciles und ovarian 
disease fejuently cn-exist ; the aseilic fluid bting of the ordinary 
kind; or, us ha^ been observed by Dr. Bennett aud olberB, derived 
from a" ovarian cyst by pasaJng througti foramina in its valla. 
When Iheee diseaEea nj-oxiftt, fluclnation, if light «nd Hn|>erfoial, 
may deceive; hut if the fiagenj are pressed more deeply, a peculi&r 





OVARIAN DKOPSr AND TUMOUliH- 331 

diagnostic mark is obtaiDcd by tbi- Biroke cf ibe fingeTs ligairist ihc 
ovanan cvst — after ditplacing the ovt-rlying aBcilic efluaion. If tliere 
ia slill doubt, we may in some cases be juslified in drawing off a few 
(b-opa i>f Lbe fluid by a small trociir, nin] aBcertaining its nature by 
proper tests. 

DubiesB on pereussion ovor the hypogastric regions Ie more 
decided in ovarian dropsy titan in asciti^s. If^ howDvcrT the pedicle 
be lon^, and the tumour t>uly modemtely largt and Dot dislendiii^' 
the abdomiital walls, bul, rathi^r floutint^ in the cavity, there may 
be Bome resonance above the pubes. In some raro cases fbis mark 
IS uf iui^Kjrtance, lu distinguishiiig the ovuriun dropsy from pri^g' 
nancy ; — in hoth caeoB wc may find on aUEcijllauon u murmur r^seoi' 
bling the plat^eutal souffli ; and m ovarian diseuse, eai>ecially if recent, 
the equivocal signs of pregnancy msiy be present. From pregnancy it I^ 
fnrthcT difitinginshed by ahaence of the IVetal heart's jinlsationT by the 
rtbhence of bdluttenient,* by tht drawing up of the uterus and vjigina 
so that the cervix ls with dlibcnlty reacli^d, by the harduusa aud length 
of the cervii, by the antuverted or retrov<!rLtd state of the organ, 
by tlic conimencemeut of the disease on one side, by more or losB 
i:onjplete absence of the ordinary const itulional signs of the pregnant 
stale, and by the duration and history of tlte complaint. Lei the eur- 
geoTi, bowever, never forget that with ovariaEi disease (at least of ou« 
side) tJiere uiay co-esJat au impregnated womb. 

There ia occasionally great dJfGenlty in di^^lin^ibhing a multi- 
Wular (ivarian dropay from fibrous or othtr tumour of li»e nterua. The 
tensiun of the cysts, their small »ize, and the viscidity of iheir centeutE, 
niay be such as to destroy all signs of fluidity in the ovariun mass, and 
the uterus may be so fixed in the pelvis by compression between it and 
the tunionr, or by adhesions, as \k> remlei' the aigns derivable from a 
viiginol examination ulso nagntory* The hielory of ovariotoniy tot> 
truly shews that the diseases may be raistakflu for one another by ihe 
most experienced and able physicians- The chief distinctive marks 
aro the fallowing: — A fibrous tumour is often observed first in the 
centre of the hypo^'astrimn — an ovarian tumour generally at one side ; 
a fibrous tumour grows more slowdy than an ovarian ; it bae no fluc- 
tuattonf find is generally much les9 movable and harder than a diseuacd 
ovary; it is more frequently Bccompanied by menorrhflgin and leii- 
corrhu:a; the utenia \& generally somewhat prolapsed, especially if the 
tUQJour is not of great si^c ; ihe ntems llels heavy, and cannot be 
moved without moviog the tumour ; ihe cavity of the uterus is also 
often elongated ; sometimes it id shortened ; frequently the shape and 

plurality of the tiiijiours are diHliiii^tive. 

In ilhistralion and prw»f of liie great diffienUit'a which attend ibt- 
diagnoeiB of oviu'ian disease, and of the errors liable to be madt, 

* A mcpiilflud bnllotlffnHiiiI u\Ay Iw dlBCOVCwd m ■ i'ibo vl tn'ftmn liunour, if it iJi i^f 
mfrilcTftle ^\u- and floating ia ucitk fluiiL 




332 OVAKTAN DHOPSY ASD TTTMOUKfl. 

even when the growth is so develoi^d as to appear to tlemand an 
operation, we may cilc the following fact io regard to 162 caaes in 
whidi incihioti of the ovary was atiemptetl. In 60 of these there was 
eilhtr no ovariaD disease at all, or its removal was Jbund impracti- 
cable.* 

Thp mn.nnj3femont of ovarian dropsy is oilher pallintivo or radical. 
Besides the ordinary treatuient for intercurrent atlacks of inflammation, 
deraugementa of the timctions of tbe stomachy bowels, kidneys, aud 
bladder, the most important, palliative measures are tapping and prea- 
Bure- Recourse to the former lla*^ been re CL>miiie Tided early iti this 
affeclion ] but it ia a vi:ry qiicatioiiahlo proceeding, and one, buaidea, 
^vhioh we rarely have an oppotluuity of trying, as women Boldom 
complain till the dJKeasc is far advanced. 

Tapping is not ads'isable, except under rare circumstances, till tbe 
accnmulftlion haw become intolerable to the patient, from its large size 
impeding respiration and progression^ and causing uiach lo<:al pain and 
Hiiflerin^ ; perho|i3 ]jroducing vomitings or BiipprcMion of urine, by 
pressure on the Ktomaoh or kithiL-ys. It is a very simple operation, and 
the danger anpposed |o atteiKl it in ordinary ciises has probably been 
esaggerated, in the statistical tables of Sontham, Safford Lee, Atloe, 
and others ; which, embracing all caseH, do no doubt include many in 
which it was resorted l^ in despair, or as a mere palliative — tlie 
(latient's strength bt^ing^ already worn ont by llie diseiise, or com pro- 
mised by some otlier aiTi?clion. The dangers chiefly to be sppreh Rinded 
are syncope, the hgiiling up of suppurative iii Ham mat ion in the lining 
of the c}'st or cysts, and the sapcn^entiun cf peritonitis. 

It is performed thus: — The patient having been sealed ou the aiJe 
of a bed, or on a chair, has tlie abdomen tigbljy girded by a sheet or 
tln^jEiel bandage ; tlie ends of i^hiL'h ai'c held hy iwo assistants, iliiectcd 
to pnll steadily and finnly P3 tho fluid oscapes — so as to maintoin 
ei^uable pressure on the ahdumiual coatents, and obviate the sadden 
loss of support to thesc^ which might otherwise occur, and from which 
serious hemoirhftge might euRue by the giving way of one or more 
abdominal veins suddenly deprived of their ordinary support. Or, 
iade|K'ndently of rupture, alarming Rvneope might take phiee, from 
great or Eiiddun accumulaiiun of blood within the abdominal veiiiB--f 
It is wpU to ascertain that the bhidJer is empty. An aperture having 
been made in the bandage, aa inciEJou is made ihruugh tbe skiti and 
fascia by a lancet or scalpel ; and thea perforation is completed by a 
large trocar and canula. The trocar having been withdrawn, the 
eanuln remains, anO through tliia the flnid cjwapesj ihin and albund- 
noue, or viscid, ropy, and variouely dificolourod. Fluid having ceased 

-Lanoel,D«. C, IflSl. 
t D J keeping tile juLUvin borluiuuil na lUe bMi?r iLurUig Oic wholp perlud of tlie 
i»|ii<r4tiiiTu tbe DCA'^lTy for bjindo^in^^ ami prcitr^ure intiy #i>mQtiuLe»^ U} in a j^ruat mta^ 
nuro lupvraedpil. 



1 




PARACENTESIS AllLlOMiNJP. 



3;(3 



to coiinj, the caniila is withdrBttiii the wound in cavereil bv a compress, 
jiiiU tlie general bandag« i>f llm abdoraiJD ts drnwEi lightly and ficcijied. 
This cTire bj lapping ia un excoEleiit inatarico of the Burgeon taking a 
lesson from th^ plans Bnmetimes luinpted N|xmtaneourtly bj Xature, 
Esiimplea of Ihe simple cvst, and oiort rarely of the miillilocular* hare 
been enroll by spontaneoiia discharge of the eonlained fluid from open- 
ings through the nmbilicua, or some olber part of the nbdominal wall, 
or by discharge of tlie fluid per vaginnni or per rectum, 

The point iisnally selected for the opening is ia the linea itlha, 
ttbi>nt uiidwfly l>etvroen tlin umbilieuft and symphysis pnbis. But it 
may be made in the ILnea seoiihmaris, if the bul^ng of tha ovarian 
cyst render tbntlotalily jireferahle. 

By the use of pressure after tapping, the walla of the cyst are m-ide 
m coUivpse, and the mass comefi lo form a comparatively small firai 
tumour in one side of the pelvic When such pressure h resorred to, 
it sltonld he. tcppt up for eome montha; as ihet^ tumonra have been 
knowu to refill, after they Lave lain in the pelvic cavity for a long 
time collapsed and causing no incf)nvenience- The nse of presBure, 
if it cat! he htinie, and he regularly conducted^ is decidedly of service 
iu imiieding growth of the tumour, aiid refilHng of the sac after tap- 
ping. 8ume vtry inLuri^sLin*; casts are TL-cordtd, where infliramH- 
tory diseiise^ atlaoking the cyst n.nd its seron» investment, has induc^jd 
such induratiunf and caused the formation of adhesions bo stroDg, as 
to resiKt furiher progress of the tumour; curing the diseaeo by 
mechanically arresting its pj-ogress. But the cyeto-sarcomatouB 
tumours, the librous, and the malignant mioses, which are not unfre- 
quently fuuud iu this tiiLuation, f^ilher :doim vr nloug wti\i the multi- 
loeiilnr cyst, are^ of couftit^ njt ametmhlu to any method of diflcuf;sion. 

As aitsiliaries lo tapjiiog and piesaure, the only remedies to bo 
recommended are iodine and diuretics. The former may be used both 
externally and ialernally. That ibcy may be of some service, we have 
evidence itt Ihe fact occiiBionally obsf^rved, that the rapidiLy of the 
growth or refilling of an ovuiian tumour keeps pncu will* die dimi- 
Qutioti of llic urinary secretion* The reuiarkable iiierease of this 
tecretion ofien obi^yrved for wmo ditys after tajiping, is pomi>times 
accompanied by progreBsivc diminution of the tumour, whi;:h recom- 
mcDces to til] only when the urine Jigain diminishes* In general, 
after tapping, tJie cyst speedily refills, and the operaliun is repeated as 
before, the cjst usuiilly filling more rapidly after every repetition of Iho 
operation. The second tiip])ing may not bo required till after eeveral 
months; hut suhsi-quenlly the interval may diminish to a few weeks. 
Thb process generally exhausts the patient after some yeace, or an 

* Bfjmy Atithdr? uf nnio entirely diitcn!<Ut tlie efficaiiy of «11 laLeniil rcnu!^td. Bams 
tmyt thfy bavo aa t^gaitl uft'wt " over the mnliguralion of the |-»nci0T>t'ii muc,'* HdmiltDD, 
u IB well kitowD, us«l Ihe wlotion of ■mriale or Ibne iJiLcnuilly vi a UiflcuLicnt, uid 
plu-vd great coDlidenoe ia IL 




33d 



OVAHIOTOMY- 



iiilercuTTenl attack of inflammation in the cyat, or in Ibe peritmietitn, 
may prove speedily falal. Someliiae^^, however, jiatients survive tu 
have the tapping very eften re[H?ared, and almost increilible quanlities 
of fluid have thus been drawn off from the same woman,* 

These tnmoiirB may be dealt with heroicn-Hj, Atteaiptfl may be 
made at eKiirpiition. TLe CkperaLion ih very simple. The pftrieot 
having' been Biiit.ihly arranged in a room of elevated temperature, a 
wonnd (a made through the parietcs of such an extent he mny be 
necessary. There h no good reason for incising the whole abdomen 
in all cases, fnjm the ensiform cartilage to the aymphysia puWs. The 
external incision ^hould be proportioned to the bulk of (he tiimonr. 

The diesectioQ is to be careAdly oondntited till the tiitnonr be 
bronght info view, attention being directeil lo arretit as far as jiofi- 
eible all bleeding from the wound. The iumonr, its rttnio as to 
adhesions^ and its pedicle^ are now to be examined ; and, if deemed 
advisable^ the o[>er;ition is continued. Unless tlio ariheBJojjB are 
very Himng and extensive, ihey do not form an insuperahle obfelaelCi 
The tnmojir ib to be turned out <rf iho abdomon ] tho pedicle i£ tied, 
and then divided; and ihe tying may \ye an managed as not to ircbidci 
any of the perilonev.m — this haviug been y^eviously disseclcd off. The 
wonnd and the aumiunding viscera are s^ionged elean, and the i^'ound 
closed. If nnfortnnalely the bowels ctinnot be kept within the abdo- 
men during the operalioEi^ meaiis mubl be taken to maintain in them 
their natnriil licat till thoy arc replaced ; they may be immersed in 
water at blood heat, or in fine linen moistened with tepid crater. The 
ligature of the pedicle ib brought out at the lowest part of ihe incifiioa ; 
and last of all, the woimd is closed by the interrupted Biitnre^ in such 
a manner as to eipofie as little as posflihle to the surface of the bowels 
beneath. This is efiecled by paHsing the needle close to the peritoneal 
Hurface of the wonnd* Tho interrupted qnilled aiiture moy HOmelimeB 
be of Her vice. 

In conducting the first step of tho operation, the plan proposed 
by Dr. Frederick Bird, to avoid misehancpK, may be resorted to — 
namely, to make at first only a small wound into tlie peritoneum, 
and lo explore tbe tumunr with the Sngcr and protte ; so ascertatniug, 

• Dr- Mpal's jjHtipnt, wliose endurinceia celebrated in tlie following epitaph, hw now 
unrurtunntely bceti frcqucaclj surpiiAr^d. 

" IlEire tied Dune Uory Page, 

Relict nf Sir Grepiry Pji*^, fiart., 

Wbo <h*pnrlpil lhi» life Slin'h lilst, 1728, 

In ibB Atitb year of ber a^e. 

In <E7 monlba i-\ii.- wu tn|)|j<:il Oil timbe, 
Hdd roiken avuy 240 ;;alloiiri of wuter, 
Witliout over revining al boi cu^ 
Or uvfD rmrine Uic o|rt:raln>n. 
l>r. Mirtinuauuf Norwich lappwl ■ pfltiflnL 80 diff>rcnt tiraea, and dreir ^flf 6833 |iiiit« 

ofAiild. 



OVARIOTOMY. 

to flome eilent at least, the faaRibility of completing the Qperation 
before (he patient Ib compromised by further pruceediL^a, At preflent, 
great hostility to all audi operalions ia declared by a large hody of the 
profession. Tbere are cases, however, which mfly certainly render a 
duly conducted attempt quite warrantable ; when the tumom" is noii- 
malioTiATtt, f<ijiglc, raovablo, and ctjunectcd with u narrow pedicle ; when 
lh« patient is Apparently free from other diseme ; wben the oflcels of this 
tiimonr are such as to threaten death by esliaimtion at no distant 
[wriod, milefis relief be obtained j when the ordinary palliative treat- 
ment, after tlue persistence has failed to give relief; and when the 
palient, having lieen made fully aware of the risk, is resolved an<i 
wishful to undergo the npcrn-lion. Modern c^pcritnce him ci'rtainly 
dooioiistrrtted, ihAt free incision of the abdomen, \\ith exposure and 
manipuhition of tlie peritoneum, is a less hazardous procedure than 
waa generally supposed. But there arc extreme dangers necessarily 
attendant npon this o^ieration — froai ita eite and ita nature, from the 
iieueflaity of leaving in Ibe wound a long cord attached to the 
peilicle, from the danger of the ligatured burating, or the wouud in 
the pari^tos pjirtially opening, in cooEerjuence of distendon of tbo 
bowels or ejlbrts in ciini^hijig, and from the risk of stran^dntiun of 
the bowel either la Hie M^ound or by the puckering uf deep cicatrjccf. 
And, besides, the following nn:Lvoidahle difficnlliea at pre^nt ^tiuid in 
the way of n general recommend at ion of the nperation ; namely^ Iho 
coufessetl difficully of diagnoai-s — ae lo the existence of eitea&ivti 
adheBiona, aa to the prcBonco of malignuit diBeoMj in the luoiour or 
in the pedicle, and aa to Ihe large Mze of the iK?dicle rendering 
deligation difficult, 

Somctimea cure ia attempted by a minor proceeding; making an 
opening in the alulominal parieles, only a few mcbee in length ; punc- 
turing the cyst. liLid drawuig it out as the conCi^uta eacape j aud then 
cutting off the [ittaclimeut, after deligntion. Snch an oj^rntion, Low- 
ever, has not been found mere successfii! than the more direct antl o|K!n 
pr(>cedure ; ami certainly it is not more easy of performance. The 
Hanger of some fluid from the cyst escaping, arid finding ils way into 
the penloneal cavil y — the imposaihilily of cleaning out the wound with 
the neeessary care — tlie imperfect deligation of the pedicle, &c., are 
obviouH objeetiona to thia mode of treatment. 

The slalifltica of ovarian operation give a mortality of about one 
death in every three coses. Its dangers, then, are very great, Oa the 
other haiul, hopes of relief from ordinary treatment of the tumour 
cannot be Bauguirie. Most women are carried off by the diteaw in 
lesa than four years. Very few have the good fortune to be cured, 
and only a email number live beyond the four yo&r?' But it will 
always Im a cliffienlt and anxiona matter for the surgeon to propose 
that a woman anffnring, it maybe, very little from thJa iliseaae, should 
mibject herself to the risk of almost immediate death, in order to obtain 





^ 



FIDIlOtIS TUMOURS OF THE UTBJlUa, 



the cbam!e of getting rid oftbat wlucli might jxissibly pi^rmit eevenl 
years oF comforUiMe existence. 

The general treatnioDt of ovarian diaeaM is still an opfii qacKtion ; 
and wc enterlaiti »;irong iind otinfidcnt hope ibat the great fittenttun 
ilrawn towards it nil], Eomo day, altain to thi? di&ccvery t)f a method 
of cure, or of a plan of palliation lanlamount to cure. But we do 
not (lurpoao to moTition hero any of the niizuerouH methodE now pro- 
[Mjsed for those objects. As yet, they hivo iDoslly proved even more 
fatal than ovariotomy, and have many additional objections. None 
have received the sanction of the profeBNion* 

Fibrous Ttmours of the Cterus 

May be found in any (jart of the organ. They may be single, bnt 
more fi'equenlly there arc several present together. They nmy vary 
in size from a pea to o man's bemh TLey rarely ocenr before the 
age of twenty, and are mofat frequently observed about the age of 
forty* Tbey do uot prevent conception, but cause great risk of 
abortion during progunucy, and lu delivery may obBtruct tbo advance 
nf the child, also favouring hemorrhage and subsequent inflammation. 
The Inmonrs themselves are liable to congestioD^ inflammation, and 
BUpjiumlion ; in conr&e of lime, tliey may become calcified in whole 
or in jiarl ; forming the uterine calculi of old author*. They may be 
developed in any [lan of the iiteriue wall ; the tiearer to the miicoua 
laoTobrauc, the gri^atcr is tbo bypcrtrt}pliy of the oterino tieauo. When 
the tnmour is Mtuiited near to llio peritoneal or to the iducouh Hurfnce 
of the uterus, it may be protruded from tlie wall of the organ in a poly- 
poid form ; and, the pcdiele gradually diminishing in size, the tumour 
may drop off into the peritonea! cavity in the one case, and in the 
other may be esjx'lled per vaginam. 'When the turaouris near to the 
macoud surface it is sometimcB fipODtancously disebargcd in anotlier 
way, us li an been obnerved !o oecur even in large tumourB; and not 
imfreqnently tlis result lias followed the irritation and preKSure caused 
by the efforts of Jelirerj^T ^^^ ^^^ tiesiies interposed between the cavity 
of the ntenis and (be tnmom'. ]3y ulceration or sloughing, an open- 
ing ig formed in these texturesT and the wibaiance of the tumour is 
exposed ; disorganization euaiies iti the loo^ areolar tis^io connecting 
the tumour to the uteni<t ; contrnctions of the bypertrophied uterine 
tisBue supervene ; and eipulsion of the tuuaour, iJi mass, or more gra- 
dually ill partf!, is the fortunate result. This may be c?iilled siwnta- 
neous emieleation ; a pt'(H:eEs which has been imitated by art in some 
cases. If the tumour hecomei? polypoiJ, dilating the cer\'ix or lying 
in the vagina, it may be treated as an ordinary uterine polj'pus* 
But it IB to be remarked that mor« danger of uterine phlebitis atlends 

* Baile elAtcs ttiat in v/ijmen qbove tbirty-flvE yean vf pgf, fibrous tumnui? art 
found in one out rtf I'Tfry five. 




QASTEOSTOMY AND OASTBOTOMV. 88T 

the removal of this form of tiimoar, than oS tbu ordiii4br> Qtorino 
polypus. 

The symptoma attending the presence of tbese tumoara are neither 
constant nor Jiagnoslic. Physical CTLjimmation filone can detect their 
preacDce and decide upon their nature, TLey are generally accom- 
panied by feelings of wciglit, puin^ or uneasiness in the hypnt^aslriura, 
and pain io ihe back, in L)it; biik-^ or iii Ihe thighs — diriurder of tbe 
functionu of urinadon and d9f;9G<:ntLon] &c. ; but eometim^s no fiymptoma 
at al! esisL Oft.en there is an increfieed amouni of vaginal secretion 
and dischargCj which may be checked by a mild iLstriiifrent injection. 
Menorrhagia not unfreqneiitly occure, and may require ibe onlinary 
treatment, if (levere ; it is generally a sign of proximity of the tumour 
to Ihp miicuiis membraiie. Occaai<i]ially, but rJiruly, lliuie is ameimrrhcta. 
If the tumours hcc:oiLC congGBl(?d and infiaiueil, ordinary antiplilogiRtio 
treatment is net'essary — eKjMiciiil attention being paid lo maintenance 
of the rtc\imbent position. If the tumours arc large, prominent, heavy, 
or movablej an abdinninal bandage op hinder may be useful to support 
and £x them, and to afford the patient a feeling of security. 

Notlii[ig can be done in the way of diaoussing these growths, 
DiBCUtient remedieBj as iodino vised cxternoliy and internally, counter- 
irritanlfi, re^t, the occot^iond local abstraction of email qnantities of 
blood hy leeching or cuppin^^, Lave often a beneficial effect in rom(»ving 
disagreeable ajTnptomg, and Bomelimea fcem b orre^jt grontb, or even 
cause a diminution in size — probably by removing the surrounding 
Bwellhig and eii gorge ui en t. 

Gastroatomi/* 

Tn the ease of in^nperahle obstniction of the pharynx, nesophaguR. 
or cardia, it has been proposed to o|>en the stomach by direL;t incision ; 
attaching tbe tdges of the opening in the stomach to the integumental 
wound ; and thus couatitnting a pemaaneut aperture, for the introduction 
of foudf Hiuiilar to v^hat occurred accidentally in Alexis St. Mur(in. 
Tho operation is fcoijihio in theory, ai^d sicnple in pt^rformanco- Bat 
ita eKteasion to rases of hopelesa malignant disease Feems scarcely 
e:q)edient.-t- 

Gas/ro/^inj/. 

When tbe trowels are obstructed from an internal canse, beyond 
reach from the outlet, a quosLion aii&crt aa to tho expediency of per- 
forming gastrntomy, ^ith a hope of reli<'ving Ihe ohntnietion. If that 
depend on hands of lymph, or on intussusception, a simple manipula- 
tion might snflice to liberate the affected parL But the difficulty of 
diagnosis, and chance of failure, besides the danger of the operation, 

* From ^itfTu;, filomicb; iuieI rn^i moutb, 
t Sttiiun, Ga»Ile Ucdicolo de Vims, Jan. 1847; and Mrmllily JouTn^l, Ajiril 
1848, Kelroi-pcrl, p- OS. 

Z 




338 



AFFECTIONS OF THE UJAIIIRAGM. 



conspire to enforce great canticm id resolving on Ruch eerii»us [Jrocertwre, 
At the sfime time, when all ordiniiry mean;* hnvc fmUd, when *KiYcrrU 
i\av^ have elnpecd, nnd wlieu the ciiBf ia othcrwieo certuJnly lioj^elesn, 
the doubtful chance oi" lliL- operatioa niiiy he afforded ; njore especially 
when pnin, nnil other eyraptome, point §omewhat plainly lo some pari 
of the ahdotnen as the prohahle eitc of obstniction. At that pnrt the 
inciBiona are made ; with the precautions alreaily tpokcn of. Ii may 
be happily in our power Bin](fly to diaentani;!© and relieve j or, al lh<? 
worst, the distended bowt?! may he evacnktt'd by [lunotiire, iind an 
attempt made at cstahlishiag the tondiiion cf ELitificial anus. Of 
twenty-seven patients operated on, Mn Phillips mentione thirteen, 
whose lives have been preserved.* 

Afftctians ijf the Diaphraffta. 

Snr^cally, the diaphragm may lie affected by pm^/ra/mj; fround. 
Tills may prove formidable by liemorrhago, or by inflammulion, and 
baa to be trtated accordingly ; orj those dangers avoldt'd^ an imperfect 
cksure or weak cicstlrix may invito protniflion of the ab^lomiml contents 
at the weJik poiut,t muie esptciully wheti thj*t lia[ij3ens to bo on the 
left mde ; and this may lie followed by a Biidden crisis iiidnceil by stran- 
gulation of a diaphragmatic hernia; or, from simple mi tip lace men t, tlie 
thoracic organs may tsnlVcr chronic disorder, not without a ritik of idtitaato 
asphyxia. 

littplurf of the diaphragm may be produceil hy external injury or 
viuleni laufH^uUr eflori. The risks by coiisei|Uetit mibplactJiaent uf 
the iihdirminal organs arc as in the formor (jaBc. 8tii;h unilpoeLiion i^ 
usually indicated by an anxious osproj^sion of ronntornnce, a Ronk 
empty etatc of file abdomen, corresponding- fidness in the diest, thoracic 
percussion iinnHJually clear or unusually dull, anscullaliou affording 
twrborygmi rallicr than refipiratory mtirmnr, with obscuration of the 
wands of the biraru Tn iroalmeiii but liillc is in onr power. 

Shonld pttrriltfsis nf Iho dinphrafpn co-esiBl with aseites, obviously 
great can? is Rpeeially necessary in withdrawing the fluid by paracen- 
tehis, lest dangerous collaphe occijr.J 



Trnvcra, Inquii^' inlo Uie PmccM of Nnf are in Rcpftirinff Injiiriefl uf tlie InlHatincn, 

ExtnK'Eion of DL?tn*^c] 0*"flrirfl, Edin- ISl^. Fingerlmth, Di&^rtntio do ViiLnoriim in 
IntoAlbb Saturn, UoiiDt 1S27. Wc1>er, dc Cumaills Intesf inoriun VulaerihcLa. Reylurd, 



* Pbillits, Mfd' Chir. Truiruu^t- toI, s^\\. Lond. ISltl; dtao tSrit- and Por. JCer. 
April IW-lfl, p. A^\ 

-f Kir Gullirlb i* nf opinloD thit n wonnd tnaM id the dinphngn nrviT beolt by 
clpiini^r 

] \\iv C> W^. Memi-ub, dia Kmnkhpiten iler Kvrerflif^lh dea MenAclKiii Etdk-bL-n, 
184ft 1 (ds« Briluh qnd FonHgn Mci1. Bev- .Tulr IS17» p. ICS. 




BlBMOOltAPHlCAL REFERENCES. 



Mnmolrea sui le Trititenipnt des Amis Artlili^i^lx, Ac~ Paris, 1S27- Jobert, Trutttf Ae* 
Vi».[nVH-tt Cliinirgirrilrfl da C'jinjil In|'>.4t1n4l. I'ari^ IS29^ Vflpcau, Mcnuiin* >*iir TArui* 
OrotiB KatuTfii Sec. Paris, lB-3tt. Diipuytrpn, Ua VAmu Contr? Nutufe, Ac ].*^na 
Or«le% Ac vol. ii. p. iy3, UTrrcnt^i^ on Itoptnr&i. Lona.l?*:iS. JVale, Cvdqi. orPrw- 
ticul Siir^iy, flrli(.lo Inttjlinil Fitluln^ Lon-1, H141. Philli|ha, Me<l. Chir. Trans. tdI. 
ixxi. Clay, Cases of Pi^riliiiicul Swtinn for tlip Ejilirpntinii of DiBcaaed Ovflrio, k^. 
MtditaJ Tiiiiffl, vol. \\u j.p. 4,^, 59, ft7. 83, flS, 139, 153, 270, Pliyiip'*, Med, Chir- TmoB. 
\N)L xxvLi, p, 473, 1^4, Lfc, on TiimDiira of iIk- t'Ktrus anni ib Appenil4igi^4] tyontL 
1917, Brigl^t^ Giiy'ii Ilotpitnl Rcporta, BoJrin md Diif^i^ Disenaes of the Ul^nifl. kc 
Cruveilhitfr, Annt Pmbnl. li^TniK, /», ic. Stymnnr, on Di^i-aaes of the OTnriii- KaucJie, 
Unlod. TiTipr. aux Femiuc*, L«^ Cydup. oT Israel, Afeilic. art, I^iscntri t^ tht Oraiy. 
S^mpsca, Library of htcdidrit, voL tr. Erichmit on Ovariotomy, Ahm>c JouttiaI, Jim. 
13, ISM. 



I 





340 



REDUCIBLE 



CHAPTER XXVIIL 



HERNIA. 

By Hemiii h im*l*'rHtoo<l n. iipotniRion fmm wilhin an inlemnl cavity, 
of part of llie cont^entw of tlmt cuvily. But llie term is usually limked 
to iLg mtiTit frequt'liL form of Mich proLniBiou — nftmely, lliat from the 
mvity of the abdomen. And of this Hernia there are vaiietiea, 
accordhig to tlie siU' of the jiroliiisiun i Inguinal uud Venlro-ingiiinal, 
i'V'mural, Umbilical, Vcnlrnl^ Phrenic, Perineal, Vn^nftl^ Lahial, 
Ohtnnitoml, TschiiLtic Tliesi^ af^ain, ma^ 'vary ai^cortVmg to the 
anatomical relation of their ^mrle — Congeuitnl, Infantile; and accord- 
ing to iho parts protnide<l — Eoterocek, Epiplocele, Entero-epiplocele, 
Hernia Litrita. And, further, otLer varietieB depend on tic pailio- 
Ikgical coudition of paita — Reducible, In-eiludble, lueurcerated, Stmi- 
guJatcd. 

Thp Cnu-tea of Hcniift are predifipoBing And exeiling. lYliftlever 
weakena tbc abdt>iuinal paricles at any point, pre<li!^|>ow-s to protrusion 
at that point; — natural want of closeness of dovelopmeut, hs at the 
fToiii and nave! ; rupture of muscle and faJ^ia, at any part, as in par- 
inniion ; atn»phy of muscle, following hnuse ; penelraiing wouud, 
Agtuu, whutcvcr tciid^ to propel the nhdoniinal contents with imusnal 
forep aj^iiist such weakened or prpdippus^^d parts, directly exeitea or 
causes the ptdtrueion ; as violent coii^hiug, straiidng at stool, or seyere 
mufieular exertion of any kiiid. And, further, the predisposing and 
exciting cause miiy l-e the same. Cough, straining, or habitual exer- 
tion of the alnioniinal muscles in any way, when long cooliuaed, tend 
io wcniien iin4 cnlurgc the nalnral uiilk-ta of the Oftvitv, by coQataDlly 
projielling the ahdorainal content*^ against the partetes — and tins prove 
predi^wsiii^- And then some sudden cough or strain effects pTotrusioOt 
and pmves thi* exciting cause. Hence il is, that old men iviih coughs 
■ and uriiianr- complaints, sailors, gymiia&ls, Ac, are especially auhject to 
the ordinary forms of ihia disease. 

The coftipvncut piirtg of iLe tumour voiy according to the nature of 
the protnifdop, IJut, generally, Ihey may be stated to consist of 
Covering Sac, and Contents, 

The Cova^ings are far from onifonn ; didertng in the varieties of 
Ilenda, and being seldom eiaclly the same in any two cases. In 
[iigiilnal and femoral hernia, for example, the coverings differ widely ; 



HERNIA. 341 

and in each of tlic^e o^ectiuiu^ tbe deiwitjf tfalclcDesH, adU even num- 
ber of the inTeBiing layers, depend very mucli ua accidentftl circum- 
sUnces, In operating^, it is vain to loot for ftn imvBryiiig sninenesa in 
(Lis part of the tumour. In all cases of ordinary hernia, however, 
there is first the usual integtuneni, and then one or more b-yera of fasciie. 
I'liese will be enuiacrated, in the separate consideration of ibc varieties 
of hernia. 

The &ic is the portion of parietal peritoneum which ia piiahed 
before the protrucling vincus, nnd whldi fiirniB its immediate envelope. 
Sometimes it ia wanting; as in hernia foUowing directly upon wound, 
and in the cungenitil form of the disease. In the great majority of 
cases, wo are to count uj^on its presence — ^idhcreut or not to the extra- 
ahilominal parts with which il is in abnormal coutact, according to the 
daralioii of its presence thcre^ nnd the occurrence or not of plastic exn- 
dfttioQ of its exterior. We ordinarily speak of the neck and body of tbe 
sac, aa we do of the neek and hoJy of the general tumour; the neck 
being that portion, of smaller Cidibre, \tfhich is at and neftr the aper- 
ture of protrusion, and the body being understooii to be the more gloliular 
swelling beyond. If the Unnour liave been long prolrniled, without 
reductiou, and otherwise but little altered in ita circumstances, tlje neck 
of the BflC is apt lo beoome dense and unyic^lding in Btrucbire, and the 
calibre in consequence is at that part of a fixed nature. When, nnder 
the applicalion of a fresh e^teithig cause, a new protnision lakes place, 
there is an extension in the sac, conTsjiondin^ to llic increased bnlk ot 
ita conlenla; hut, not improbjLbly, the propelled orij^'inal neck of the 
sac doea not change, except in its jXFailion only ; and, rtmfuning of itu 
ccotrcLcti^d diuicntdone, it may becomo the aeut of Btrieture in the case 
of strangidatiou — the new neck proving comparatively free and accom- 
modating'. This circumstance has obviL>usiy an important bearing on 
the operation lor relief of sirangidatiun. 

The llfmial Contents are various, InnBmncb as every abdominal 
viacnr* is liable to prutm&ion ; but the moat fitqucntly affected, by far, 
are the intestines and omentum ^ ona or uthef, or both. If intcatiae 
alone is protruded, the tumour is said to be an Enterocde ; Epiplocele 
implying descent of omentum ; nnd Ent^ro-cp'tplocrAf^ descent of l>oih. 
Sometimes only a reiliindnnt j'ortion of bowel esL^aties, in the form uf 
a diverticulum ; and this is termed a Hernia Litrica. 



The Diagnosis of henna is a [H'acfical Hubjcct obvioiialy of the 
highest importance. Ordinarily, a hernia is found to be a soft tumour, 
at the site of an abdominal aperture, receiving an impulse on coughing, 
and tending to erdargement under e^iertiou of tho abdominal muscles 
in any way, gnrghng under pressure if contaliiing bawd, nud capable 
of being replaced, by ptcssurci within tiie abdominal cavity. Thoptj 
are certain aftections for which such tumours are especially liable to be 





U2 



UEllNU. 



\^ Cj ^ 



miataktiii. I. //^(^roc^^ GimulateB the obl]({ue mg^iDal hernia; but 
is lo l>e difltinguished ihua; — Hydrocele is goneraily more or less 
irautilncf^nt, and bernia ib altooEt always opai^ne; the exception being, 
when in a. l&rgc hernia, inveHied \'j (hiu integnrocnt, a fold of bowel 
alonf- dc^Ec^nds, capacious, and filled only with gasernn contcniB. 
Hydrocele is a coastant tumour, unaffected by pressure ; hernia ie 
. ever varying by accidental circuni stances, and is usually capable of 

)ROwt, L L^jjj^ diminitihed by pressure, if not made wholly to disappear. The 
;kpeJt of the pyrifonn swelbng, in tiydrocele, simniaieB ibe neck of (he 
licrnin; but, on cajeful n^anipulatinUt it is ibimd U\ termbate beneath 
the abdominal onttct, leaving alwara Eom^ y>art of the cord clear ; and 
ihe cord is never at any part clear in unicdiiced hcmia. The hydro- 
cele, unless con^nital, has no impulse, and evinces no tendency to 
enlargement, on coughing, or other exertion of the abdominal nnisclea> 
The testicle is felt obscurdy, if at all, in hydrocele ; in scrotal hernia 
it ia usually found, distinct and Be^Kiralc, iit the luwyr jiart of the 6cn>- 
tnnj, Tbe hiaiDry of the cuk<'j too^ ia widely different j tlie hernial 
liiniour apv>cars suddenly, and proceeds in development from above 
downwards ; the hydrocele is of gradual formation, and its progress is 

iPO''-^^ from below upwards. Not unfrecjuently, however, be it remembered, 
Hydrocele and Hernia co-exisl. 2. Ht/drocele of the Cord, — Thia is 
uoually a circumscribed swelling, leavlnj^ a fhirlion of the cord cIbat, 
above and below, as may bo ascertained by cartful msnipulation ; it \n 
not reducible ; and it evinces the ordinary negative s\gn^ on coughing 
or other eierlion. When the portion of cord within the inguinal canal 
LS affected by circumscribed seronB accumulation, however, the diagnonis 
may become of great difficulty, as can readily be understood — resting 
mainly ou the reducibiliiy or irreducibiliiy ijf the tumour. 3, Cirso- 
fcic, — Ordinary varix of the spomiatio veins, and veins of iho scrotum, 
can Kcart*ely he mistaken for hcrniik ; the cord ia comparatively elr*ar, 
the feel of the veins iE marked and cbanicteristic. Like hernia, there 
is diminution of the sweUing during recumbency, and on prcBsure ; but, 
unlike hernia, there is return of swelling, ou resumption of the erect 
posture, and on abdominal cxeriioo, though the thumb lie kept accu- 
rately mid firmly placed on the ahdomiual outlet. When there ia a 
swelling, however, at the upper parE of the cord, partly within the 
inguinal canal, and consisting oi enlarged veins — ]>erha|>s with some 
serous accumulatioa — diagnosis is difficult ; for the fonn and hihtory of 
the tumour are vei7 like those of hcmia, and there is an impulse ou 
coughing. We triiHt to non-reducibilily of the entire swelling, and 
its charaeteriBtic feel ; on piaohing it, the veins roll like carth-wernjH 
between ihe finger and tbuinbr and the touch of the eK|i*'ricnc(?d is 
usually able lo delect the absence of all abdominal descent. This 
swelling, however, oflen paves the way tor hcj'uia by dJlaling the 
canal, ami thereby facilitating prolrtiwioa. 4, liub'i. — The history, 
progress, form, jmd feel of bubo must obriously differ very much froni 



^{JCt '*'- 



iVi^C) 



4 



HI3DUCIELE HERNIA. 848 

tbose of hernia. T!ie two way "be combin^^ however; a patieDt 
jifHicted •with inguinal heraia, or femoral hernia, may havo pnlargfi- 
ment of the inguinal glands. 5. Desc^it of the Testicle. — The testicle, ut SGl 
desCTniling at an muisually late period, may be arrested in tbe iDguinalQp TFS' 
canal, causing a. painful swelling there very similar to hernia. It u 
known, by iibtwnc:e of tUo te&tielo in Umt tide of the ecrotuin, "bj the 
fcul of tho tnmoiir, and by tho charactcriHtie pain which is esperienccd 
nil pTQRHiire l>ping made on th<^ pari. I.ikp the higli form of Cirsfhcele, 
it niiiy be the precursor of henna; u porliun of bowel or omcnhiin ^'p^RCOO 
slipping down behind the testicle, through tbe abnormally dilated cEinal. I 

6. Swcucefe. — This is readily (hutingnished by the hislttry and prngress 
of the tLUn(jnr, it» fvtd and furni, v.ud lit, neguLivi- bi^^ns on coughing \ 
th*? cord too in free, except in souio caaos of malignant diacftso. 7. r-*^0^ ' 
/*j/jnjf /rijf^rw in diBtingui^ihed from femoral hernia; by tho evidencea 
of Kpinal disease, by the history of tbe wise, by distinct fluctuation in 
the Bwelling, and by the prygrem of *^i>oinlinp;" and most frequently 
the site of Ihe absctss is exterior to that of hernial protrusion. 8. . 

Vitrix of the fi moral vein. — A bulging vari-t of the femoral vein pre- ^ n^^r- 
jecting throngli the eaphenic opening, may very readily bo mistfikea 
for femoral hernia. The test is Kimple, Rednre the ewelling by 
pressure in the recumbent posture, and theu press firmly on (be abdo- 
minal outlet; if the carie be one of henna, there is no reproduction of 
tumour; if it be varts, the awdliug; quiekly reappears. 

KeduciUe Hernia. 

At Bome pnrt of the abdominal paiietes. a ewellins forms; pain- 
fiil ; sudden, usually aflor tome nnwontcHl exertion; at first slighlly 
tense, aiid tender; afterwards soft, compreasiblc and lolcrnnt of mani- 
pulation ; increawrd by the erect [jostnre anJ by abduminal esertion — 
and tlit'D, loo, &nr4luining an impnlse, vhen held; callable of being 
redncL^d, by pressure made in tbe dirot'tlon of the outlet throngh which 
it has come; often disappearing ppontaneously, on recumbency being 
assumed. An entcroccle is Kmc)ot]iT elastic^ and more or less globular in 
form ; It gurgles on pressure, and diUulent noises nay be emitted spon- 
taneously ; reduction, under jircssure, is preceded by gurgling, and is often | 
abrnpt" — ^tatiug phiciCfrr aaltu.}**. Epiplocele ia dunghy, and more irre- 
gidnr in form ; it t-mits no noise ; and reduction is slow and gradual. 

Tbe treatment of reducible hernia may be regarded as analogous 
lo that of dislo<;a!ion ; conbisting of preventioo, reduction, and reten- 
tion. Not unfrequently there are premonittjry syniploma of prolni&ioTi, 
and then JWveitiim is in oiir jtower, I'aiu and slight fiilnesa ap|>car 
at an abdominal outlet, after unnsuul exertion. Hernia in about to 
ibtm. In order to avert it, the exciting cauao is removed, by diroon- 
tinuu]": all abdominal exertLon^ as much as possible. And the predis- I 

posing cause is met, by a well filted, lightly springod truss being worn 



L 




3^4 



REDUCIBLE HERNIA. 




on the part, so as to etren^hen what is weak in the [mricte^, wbile at 
tho same time il mcchanicnl obstacle is directly oppof^d to prolruEion, 

Should hernia at; Imvlly form, replacement^ or Reduction, cannot Ix? 
too Hooii t^fTL'Ulvd ; inasujucli as the parts pivitrudud aiii ever liable, 
from apparcjitly but blight cauttca, to the Eiiporv^<ution of stntn^rlalion 
— a Plate fraught witii thti utmost ilnng^r to life. To leave a heniia 
nnreiliiced, anJ at the same time to continue any labadous avocAtion, 
or evun to bo exposed to but occasional abdominal exertion — is to con- 
vert a comparativL'lv unimportant disease into one of a grave character, 
and tu render a lilV, oiherwiee good, depcLulent on a very slender 
tenure. In lifo insiirjinee for exainploi an applicant affected with a 
sligbt but well tnj.eped herma is ndmilteil, if in other reH[>ectK fmitable, 
with only a triflinnf arldiiion of premium ; while he who, with as simple 
a hernia, and of equally good bealtU in other respects, neither wears a 
truss, nor otherwiHe provii^les against descent, is unhesitatingly rejected, 

Kuductiim is etltcled by plmjing ihu patient reeumlient, hlightly 
clcvaliufip the trnnb, removing all outward pi'etBure from the ahdomeu, 
and in shfirt taking every means to relax the alnlominal parietee ; then 
gentle nnd steady retro[iellenl pressure is made with the hand, in the 
direction whence the descent has come. Such manipulation is tcnued 
the Toxis. 

Hctentwn is effecled by coutiuued and suitable presaure at the site 
of pTotrosion ; and tiiia presEinre \a beat made by means of a trusa ; A 
ateel spring, with a compressing pml at the e^ftremity. Of thcBe inAtm- 
menls many varieties have been constructed; hat, of bile, opinion 
seems to have invlincd, very justly, towards a decided preference fur 
the simple spriug with its ordinary cork pad; provided that the instru- 
ment is accurately adapted to each individual cose; the pad fitting 
nicely to the uhdoininal outlet, not ttnj ti>Mical leet permanency of dila- 
tation should i)e BO maintninofl, nnd yet not so flnt as nnnooessarily to 
diffuse the pressure; the spring passing about two inches beneath the 
crest of the iliiun, grasping there firmly, and tenniiiating a. liltlo way 
beyond the spinons processes of the himbur verlehrje; the spring not 
BO strong as uy gall the parts by inordinate pressure, and yel strong 
enough io shut up the trpeEiing^ effectually ; a thigh BtrAp parsing froio 
the baek purl of the spring to tho pa<l, wo as to prevent that from being 
displaced upwards; and, to avoid chufing, a piece of folded lint or 
linen being interposed beneath the instnimcnt, at the site or sites of 
pressure. At night, the truss muy be remeveii, on the patient lying 
down in bed. Id the morning it [3 the Qr,st article of dress to be 
adjufittdj great care being alwaja taken in regard to tft'o poiutH — L 
that ihe pad fits pccnnitely; ami 2. tbat there is 00 deseent, however 
alight or parLia!, during its application. Bbould at any time repnilrn- 
ainn occur, the instnimeat must be instantly removed, and means t^ 
instantly taken for repJat-ement and accurate readjustment, 

By carefn] and coneUint nae of the truss, a radical cure is expected 




RE11U01BLE BBRNLA. 345 

in tLe cbild. Tho predis^wain^ cause is penuantiitly removed; for, 
dfBcciit beln^ prt-venteilj further dllalaLion of the outlet dues not 
occur ; and, during Ibe general develojiiDeDt of fltructiire, the aperliire 
or i:nual coioeB to ur^tiire the uuriuiil [iroportion und uiLpnbililieH- 
Tlie period during whitili tho tnisa rrquirea to be worn, for attaining 
thin end, is contiderahle ; from one to three, or more yearn. In the 
adult, so fortiiDate au isfiiie bf not to be hoped for ; the outlet rciuaitiG 
dilated, and prediaposftd to ro-deaeent, on application of but a slight 
exciting cause; usually the Inifls must be ^om for iife. And yet, n 
happy incident may occur, in favour of a beller issue, ThuB, we have 
aeen a phlc°;TDOD form uofJcr the pressure of & galliog pad ; the abaceas 
diH<^harged, contracted, and healer] ; antl, nn eicatri^ation, it waa found 
that the extent and site of iiUstic esndalion had Icon sueh an lo eon- 
Bolidate tho outlet, and render further tise of the iruRS quite nnneces- 
sary. And even without such aycideolal aid, it somclimes, though 
rarely, hupjiens that a slight Semia disappears under temporary uKe of 
the trusa, and does not return. 

A*;, in llie adult, the trifss, however carefully and putiently worn, 
generally proves but a paUialive, Itadkal Cnres Lave naturally been 
sought for wllh some avidity. Of these, several havt been applied to 
the infl^uinjd hernia. What seems llic bci-t method is, lo adopt the 
principlo of fiuljcuiaaeous piinctuR- ; making several scarifications in 
tho neck of the sac — tlic coiil cnrcfuHy protected — and then apply- 
ing accjuratc? pressure over ifio eaualj so as to favour occlusion of 
its unoccupied part hy plastic exudation. Another method is by 
invaginalion ; pusliin;^' a fuld of integument iuLo tho canal, after 
reduction of the tumour; retaining the invagination hy a suture, at 
tho upper part ; and ublaining afterwards adbesioij of the mvagiuated 
jjurtioa of integumeul, Uy pressure^ afler exL:oriatioo by meana of 
ammonia. TIuk, however. Is found lo I* both more iincerlnin^ and 
more Hnaate, thsn the former mode. And neilber should be attempted, 
unless in eslreme cases, and at the eipresH desire of the patient; 
seeing that neither is quite free from risk by excess of the in^ammatory 
process. The application of iodine to the neck of the sac has been 
tried, by punctarc and i:iJGctiou ; but this method does not ^cm more 
promising of EUccoBti than the other-* 

IrrRdiicihle llernia, 

A hernia ia said to be irreducible, which cannot be reduced, and 
Ltt perniuiicully ri-\cd \\\ iU ejitra- abdominal position. This statu may 
be caused— I. liy adhemon of the aac, on its estemal aspect* to tbo 
parts into which it has been protruded ; iind by adhesion of its internal 
surface to the hernial contents. lu a neglected hernia of any consider- 
able duration, the former event seldom fails to lake place ; and to con- 





346 



IBRBlJUUlliLE HERNIA, 



etituto the second, pluitic e&iicLnlion Las only tu occur on Llie apposed 
eurfacCB. 3, By the nftturu of the proUiiflion. The oaput ceccum coli 
is uncovered by p*riton*mm jxisteriorly. It inny fliirle down ihrongh 
the parietes^ Rnd, presenting at the g1^^Ull it may constitute an irre- 
ducible UuiLonr — as well as a hernia without a sac. The iireolar 
adbetions of ILo diwpluced giit have been extended and shifted but not 
bri>l\etL ; and lliey uiuy pri^gent au InMLip4:rable ob^itde tu n^jdaceineut. 
But it has bap^Tctied otherwise. The bowel atny have a more Gxton- 
give |>enluneal invefittnent tlmn nsnal ; und, inwU'Jid of merely descend- 
ing with its fleshy connexionfl, may acqnire a complete meBentery — 
BO becoming eaaily reducible.* 3. By contraction of the abdominal 
cavity. When a large iternia has been long "^trednced, \[ m&y 
beiiome permanently irredui^ible, allbougb no ailheeion form between 
the contents* and the tae. The abdominal cavity, barixig purled 
with a large proportion of its ordinarj^ contents, eonlraols upon the 
remaijider ; and tben there is found to be no room for rejdaccment of the 
extruded purls, even \vcre circnmslances quite favourable for such 
reduction, 

Lrreducible hornire are predisjioted to evil. T!ie patient UHUally 
euffcrs from flatulence, indigei^tiori^ and conetipution. The peristaltic 
movcmi^tit of tbp protruih'd lnuvf1fl In iniperfcet^ Hiid fi> oiber cnufioa af 
incarceration and slran^ulalion the jiart is conrtlantly exposed. Such 
cases, therefore, rer[nire to be watched with Timisiial care, The bewela 
are to bo carefully rc^dated ; all excitants L>f intcFtinal disorder are to 
be avoidedT a£ well na unneceBsary abduuiinul exertion ; and a bag 
tnisa must be LOiialmitly worn, so -as both to support the protradcd 
partM, and prevent the occurrpucji of fnrtln^r protniKion. No direct 
interference is warrantable^ with a view to remove the obstacles to 
rednctiujj, But, fihoiild strangnlation occur, the ordinary i>i»eralion ia 
to be performed, for relief of the constriction. 

IncarceraUd Ilnmia. 

This term denotes a temporary retention of the parts in their 
abnonujil position, without obstnitliun to the frecal Qow, and without 
the occurrence oi' intiammatory di&ease. No urgeul symptoms call for 
reduction ; but when this is attempted, it ia found to be impraclicabie 
under existing circutnBtunect*, Tbcce may be — 1. An tnUrgeuieiit of 
the heruial tonlonlH. The gaEeous malter may have beoomo expanded; 
the fluid and solid contents may have aecumulaiedin uuufcual quautily; 
or a [kortioii of eslrudL'd omentum may have slo^vly expanded by in- 
creased deposit of adipose tiiihiie ; and the tumour —thus enlarged' — is 
loo bulky to repairs the outlet, Ur* y. Whde the tumour may be bnt 
Liltlc climtgeflj Lhe aperture Ihmugb whieb it cume may he ti^mporctiily 
coatractod — preventing replace nit jii, yet not caufiiug euEiBlrietron anrl 

' Lutd, Nu. lio&^ p. 4t\a. 



i 

1 




BTBANQULATED HERNIA. 



;wr 



aLraQgulotioQ ; nnd tbis etat« nmy depend qd umaciilar spiuiii, or on 
HweHiiLg of the parts connected vritb one or other of the vaj-ious Btfiges 
of fln advnncing inflammatory process. 

Treatment det>enda plainly on the cause. Gaseons contents are 
diminislied by the cuniiniied application of coM; solid and fluid, as 
well Its gaseous couteuts, iony lit favi^UTiibly acted on by piirgativ^es 
and oLiGmatu i & fiilty omentum may Ixi dimlabhod by prGeenti) and 
Starvation ; and, then, the reduced tummir mtiy In? pnshed huck within 
the abdomen. Spasm is ovi^rcoine by the warm bilh, opiuni^ chloro- 
form, or other anti&paBmodicB ; inflanimatory esudution ib got rid of 
by antiphlogialics, followed by discntisnts; and Ihruui^h the cleared 
outlet u ccunpiiralively unchanged prwtrusiuu may again be jjasacd. 
Until tbirt deeirablo event can Iw aebievcdj tho part ought to bu anp- 
porled by a hfl^-tniaR or otherwise; and every precaution should be 
taketi to avert the occurrence of fitrano^ation — to which nuch tumours 
are especially UBble» 

Straagulakd Hernia. 

Strangulation h otxid lo have taken place, when fn^cal £ow is 
HJTGsteii in ths hernial tninour by tightni-as of conHtnction nt the neck ; 
and when, nsually from the same cause, circulation has been disturbed 
in the protruded parts, and the inflammatory procens is begun* Or 
the condition may be otherAvise defined to be; — mcnrceration, with 
iuterruptiou it both rhe fxcal and the vat;cu1ur How, liud wiih an 
inflmnnifttory pri>ccfii9 in tho protnidcd piirta cither following or pre- 
eeding constriction. For this slflle of maltern^ the hernial eontenta 
are usually lo bhimc. The cunstnction may depend on j^pasm, or 
other alteration in the abdominal outlet; but much more frequently 
it is caused by sudden, or at least rapid nnd unusual, enlargement of 
the protruded parts — in consequence of which, tJie neck of the tnmonr 
becouieB, t\s it were, Jaifimed at the npertiirc of dcE^ccnt. A fresh 
protruHion takes place ; or fiecnlent contents accnmnhite; or guKeona 
contents become increased; or an iuflaramntory process is begun in the 
protruded parts, cansino^ both eng<>rg>?raent and serous effusion. Much 
more freqiicnily, however, the iaflammalory accession is cunsequenl to 
conetriction — indeed canaeJ by it. 

The Hjmptoina of slrangiilailon are very marked* The patient ia 
;miiijyed by Ihilnk'nee and general unoasinoss. Tho bowels refuse to 
act ; the conlcnta of the lower bowel may be evacuated, but no dejec- 
tion can bo obtained from above the seat of alriclnre ; yet frequently 
there ia a Ironblesome and uri^'ent desire to go lo hIo^jI, The tumour 
is found incapable of reduction ; at BrsL it may he flticcid, but n soon 
grows lenac, Jiod tension rapidly increnseti. Pain ia fcU in the part j 
on the increase, and extending toward!^ thv ahdomon, Sickni?i<s come« 
un, with retching. Then the stomach is t-mptieJ ; nnd, vomitin;2: con- 
tinuing, the ujij-er bowels also eject their conlents; the perislaltic 



k 




T^ 



348 STItAMGULATED HEEKIAp 



it^l m&ttera are 



r 



movement comes to hv. wholly reveiwd, and thfl vomJtetl 
BtercomceoiiB, At first the pulse may huve riren to tlie sthenii: amX 
inflammatorj character j bat dow it hecomes of another Ij^w — denoting 
the slale of Constitutional Irrita,lion, mid tending fast to lapse into the 
iyphaid character. Tlie lumuiir becutues more and more lenee and 
ptiiDfiil — perhaps intolerant of even the gentlest preesure. Great pain 
afTHfitfl the whole ahdomtn, with aggravalion anil twilling nt the 
umhlliciis. NauBCii and vomiting coclinue ; the countenance is anxious, 
pale, pinched, and wet with clammy perspiration ; there \s great rost- 
lessnesHr and distress is constant ; the pulse grows rapid and indistinct ; 
hiecoughiug seta in ; the tumour lieconiea less intolerant of manipu- 
lation, leas tense and painful, and feels doughy and crepitant on being 
Iianclled. G^ingrptie him tjLhea place, Th4*n vomiting may cease, and 
Buddcu cessaliou of pain and discomfort may be experienced; perhaps 
the howels act inipeifectly ; and the patient may express himself not 
only relieved hut coiiiid^ut of recovery. tSinking, however, contifnies ; 
and the fatal issue is not long deferred- 
Such \ti the ordmary cuurac of a atrangriletcd hernia, unrelieved- 
But there m^iv he another and less formidable tr^rmiiuLliun. In the 
progress of the caae, the interment and other envelopes of the 
tumour become involved in the inflammatory process; at first Ihcy are 
bright red, tense, and very piiinful ; afierivaids darkc-r in hue; less 
painful and tense, cold, phlycteuuloiis — in fact gangrened. The con- 
tents arc ht a similar c.)ndilion. All t^lou^h. And, on separation of 
the raortifiud parts, copions feculent di^obarge takes ploce ; relief fol- 
lows immediately ; tiie urgency of the symptoms is over ; and g^adoal 
recovery may ensue, with the estahlisbnicnt of artificial anus. 

In the preceiliug; enumeration of e}"mptoma, vrc have first the 
signs of olffi true ti Lin, and then tbose of inflammatory acccsaion, in the 
protruded partn. But this may he revers«l. The hiflainujatury pru- 
cesa may be the original affcctiun ; pjiTiscd, perhnpp, by a blow — 
though a less direct and palpiihle exciting cau^e may suffice. The 
tumour is painful and red and swullen, even for some time, while as 
yet the abdomen is free from ailment, and the bowels are working 
naturally. The pain and tension are chiefly at the body of the tumour, 
in the firiil iustauce, fustc^jid uf at the neck as in primary cunEtrieiioEi. 
But, the inflammotoiy process continning, engorgement with efTusion 
takes place, the hulk of the whole limiour is Increased, in eoneciptence 
constriction occurs ; and then follow obstruction of the bowels, affeo- 
tiuQ of the abdomen, and aggravation of the local disorder- 

The rate of progress varies according to circumstances. When 
the tumour is bmall and receul, con i^tric Lion i» ur^ually light ^ and, in 
a few hours, death of the parts, at least if unrelieved, is eoiiain. 
Whereas if the hernia be of Romc mze and long slandiug, and if 
obBtruclion precede the in flammah>ry process, and neither prove urgent, 
days may elapse ere much misubief he done to either part or syBtcin- 



1 




THE,\TMENT OF QTEANOCl.ATED HERNIA. 



349 



Oq the average, however^ it is not by days but by honrt and mimitea^ 
timt Lbe rcgiatrution of lime is maile in caseH of Elrongulated heniia. 
And, by ihe practical man, tbese miniitea nre invariably regarded as of 
vital importance. 

Many if not nil of these symptoms may exi§t, indeiiendently of 
citLer hernia or strangulation. WbcneTcr tlicy do oca^nr, bowever, 
bemia is invariably to be »iiapeo(ed, acd ibe neceesary inquiry a.DiI 
esamination FhoiiU be made under all circnm stance s. Thpre may be 
no tumour found at the ortUnary siii-a of prolrusion^ or at any ctber 
accesHible part of tbe abdominal parietes ; then it is probable that the 
Bymploms are independenl of hernia — purely abdominal. If a beniia 
13 diflcoverui], of old elaiiding and conablerttble sizf j nul vtry teuae or 
painful ; if tlie pain la not greater in tlio tumour than olEewhcjre — 
perhaps not bo gr^^at ; if the boweia are acting:, Ihougb i)prhapb imper- 
fectly; if, on inquiry, it is a^^rcrtjiined tbat tbe abJominal and p^eneral 
symptoms phiJJily, and by bonie considerable time, preceded change 
in the tumour; — then th*j probability in, that the affection is enteritic 
or peiilonllic, origiujitiu^ iu the general abdomen, afft'Cliiig ihe tuiuonr 
BecoTidarily, and ptrhjipe even in a minur degree- Wben^ hopover, 
tbe si^na of Hlrangiilalion are found marked and acute, and tbebiMory 
plainly indicates precedence of the local auLl extra- abtlomi rial M^ns of 
disorder, tbere need be no doubt that the case is of tbe ordinary kmd 
— tbe urgency essentially dependent on strangidalion of the bemia. 

Trcfdmf.nt of otrangnUued hernia jiecessarily varies according- to 
tho n^ituru of llio case. In goneralj it may ho said that our objeol ia 
to effect reilurtion aw apeeilily as possible ; eiivJng atmcture, by 
favouriu*; decline of tbe inftammatoT^' process ; reslorin;^ tbe normal 
passage of tbe intefiliiial c<m[en(a ; and arresting tbe disastroiia progiess 
of constitutional dislurbance. but it la not aliv-aya good practice to 
have recount tu tbu uianipnlationB fur reduction immediately ; unci, 
in regai-d to this praciienl point, tko onaea may be divided into two 
great classes; tlio?ie wlu^'h an* prficedi*fl by inflammatory change in 
the bernia, and tboae in winch tliis Pdluwa on constriction otherwise 
produced, Tbe latter, Joubtless, aro the majifriiy. In the former, 
it is the natural and proper conrso of procedure to remove the cause 
of constriction^ if pfjssiblCj in tbe Bret iustimct — provided tbe easels 
chronic enough to admit tif ibia ; leeches are applied, and other suit' 
able nnli]ibl(jgi sties are enforced ; and when, by such means, the bult 
of the tumour has dim in J si ted, and the parts have also acquired A 
better tolerance of manipulatinDj then reductive pressure is to be 
applied — witbont risk of doing hann, and with a good proai)ect of 
proving auccesaful. The mflamnialory change lias caused constric- 
tton ; remove the cauflc, nnd tho constriotion id easily dealt with. But, 
in the other class uf cases, the state of matters is reversed. Tlie con- 
Btrictiun has caused inflammatory accession ; and, only after removal of 
the former, can we expect to cope sacceeEfulIy with the latter- 





360 



TUEATMENT OF STBANOliLATED HERNIA. 



\n employing leeches for the relief of hernia, it is well nol to apply 
them to the tnanmr itsclfT but lu its immediiile vicinily; otherwise, 
the aliiipcrine&s whicli is produced, by oozing of blood, tntty iuterfflre 
seriotlsly with The iimiiipillations iif ihe lftxl*i. 

In applj'in^ l.lie laiis, the patient ib pla<'ed rcmmbeniT sind wilh 
the limLa and (nink ho arranged as to relax the abdomiLiiil jiarii'tes to 
the fall ;* it is well iilso to sec that the bladder is emply, Jiiid that no 
bandiige, bell^ or other imiward conBlrieiion la affeciin;!?' the nbdomen. 
The tiimoiir IB then grasped with the hands, firmly yet cautiously ; and 
while with one hand geneTal pressute is made on the bulk ai»d Ijody of 
the t unto iir— forcing it in upon ilftelf, as it were, anJ at the same time 
pushing h bnck in ihe directien whence it has been pnttnided — n 
kneading or pinching movdmerit is nmde on the nock of the- tiimonr by 
the Bngers of the other hnnd, m as to dieentangle and free Ihe [jart most 
compacled and comprepeed. And this ia steadily persevered in, for some 
lime, provided the patient do not complain greatly of aggravation of 
pain and freueral niicasinesp. Our wish is lopnsh the hernial coQlen is 
back, not in niasa^ but :n detail ; those gning first which were last pro- 
truded. The patiert, if not cblorofornied, is kept in conversation, to 
prevent him from slruining bia abdominal inusclcH in involuntary 
opposition to the operator. There is enero^, yet no violence of force 
in the prPEnnre ; and it ia patiently and steadily maintained, yet not 
continued loo lon^ — that is, not after reasonable hope of ita success 
has pafiKed, and when its maintenance must inevitably Lend to seriona 
aggravation of the crescent inflammatory procoss-t Sometimes it is cot 
applicable at all ; when, for exampW, the case is acute, and has made 
great progres^ert flssittftuce ia called ^ Vkhen the parLa are so ob^'ioualy 
intolerant of presanre, as to convoy to the pmctiHcd band and mind 
tho apprehension of texture giving way by rupture under an attempted 
tJisi.^ ; also, when we are satisfied that infiamniatnry change bws already 
gone Bu far as to render Ioks of subfttance, either liy ulceration or by 
sloughiag, inevitable in the ccinstricted parts. 

Sometimes benefit accrues from an op|iOJ*ite direction of gentle 
force, previouB to the reductive application of it; bringing down tho 
jammed neck from the abdominal aperture and so favouring a clear- 
ance of the passap;e by an unravelling, as it were, nf ita contents; 
causing, in fact, a ^^ligbt increase of the descent, before the whole is 
attempted to be replaced. A bluff forcing of the fundus of the tumour 
(jn ilH neck ih especially to l^t; avoidi;d, when replact-metit is intended; 
far the effbct of this^ in tho case of protruded bijwel, ia not only to jam 

* Bv FtoiD*!' ii- i^ l-hiiLipi^lil (]i>i( rniLi'lL may \k ilitnu I't jtusilicm nl'tnE^ Huslng thv 
tliigli9, rolJitLnfC the limbb iiivnrdfl (for ininunal and frniDral bprnia — ffipccUllF Ihc laCEtr), 
niaipj? thmmteB tUl tlie wlirile weight nviU on Ihr shoidihirs, rediltiiD^ itiia fioBHimi 
Tor a llnii^, Ulitl iMnertiig hiuI rpil'Iii;^ '■g^ln, Uie hiual c>f ihv KiT^L^m nivaliwhliti (JiokJji^ 
gentle prei^iirp un iTw tumour- It is 1h4>agli{ (1ml the p<«tiiriTi^ n>ndn to puil thu luri- 
Ipninoatdf their fVic— BriL im<t Por. Rei'^ April IftGO. |>. 4flL 

f For a sjULiple of Ihe itiJiuiM done hy JmprudflDl taxi^, set T»]f on llemia, p, \f\ir 



I 




ATIXILTABrEe TO THE TAXIS, 351 

the parts yet morr, but Jtotimlly lo fnvoiir Formi<lab!ft n^^ceanion Ui tlie 
tumour's bulk liy Irflction from the aperture ilownwurfJa, 

Failing in the well applied taxis, we tiaturally look for Au3;ifiaries 
ta it; mi\ we tind a catalogue of tbese, analogous lo tho aids of 
rediK^tiuu In ili.sbcutioti. Sume act ou llm cootL-Ljta of (be tuuiour, 
lending to reduce bulk • othore aflect llio abdominnl outlet, temling to 
enlarge npace ; and tlie latter act wcOl^ not only in those canes in wliioh 
spasm of the jilMlominal piirieles [& fbe cause of constriction* but also 
in those in wbicb ihe ubdojuinal outlet may be of tho ordinary dioien- 
eiona, yet quite unfit for return of Ibo impacted texlurca which it hap- 
pens to cu&taln ; in olbcr words, tbcy are of use in relaxing muscular 
fibre, not only iu a biml^Iic but also in a normal state — making easy 
room, either way, for replacement nf the ^li^locnted parts. And liere 
it may bo etaleil, that though in many oases tlie abdominal outlet ia 
in the first inslaueo free ^(►ra change^ and constriction depends on 
alteration in Lhe contents; yet, blrangidation having occnrred, the ab- 
dominal pariotes at the site of the hernia become involved in perverted 
action, and M>unor or later arc irrilati.'d into spai^m. Ami benco it iSf 
that tlie most useful auxiliaries are euch as tend to nlnloniinal relax- 
ation. 

1, Vertcsection is advi&altle in but n few cases ; — in the compara- 
tively young and robust, cf irdhunniatoi'y tendency, tolerant of loss of 
blood; with a ci^hl strangidation yet recent, marked signs nf advanc- 
ing acute diaease in the jiarts, *nc3 tho conBtiLutional pymjitonis still 
evincing a sthotiic tyjio. In sneh cases, blood -letting^-^ono copious 
and rapid abstrattion, from iLe arm — is of use by bilh combiitiiig this 
advancing nffcctiDU, and at the Banic time tending to cause complete 
prostration of the muscular eyateni — the Bb<]ominftl parictes of course 
iucludetl. 2, Tlic Karm-bath has shiilhu- leiideneies ; and is obviously 
more generally ajiplieablc, indueing temporary dL'prcssion ; gaining tbo 
desirtnl end, yet saving the system from at^tual Iurb- If there be time, 
this is one of the best means of atBisting the ta^i^. Tho patient is 
placed recumbent in tba bath, ^^ith the abdominal parietes relaxed by 
posture; and, when fiuutness is bcgiiiuing to be complained of, the 
taxis i^ residutcly applied* It may fitll ; but the opp^iruinity by the 
bath iti not yet over- Let tho patient bo replaced in bed \ in a few 
minutes he will be found deluged iu perspiration, n-ith a mnscular 
system more probtrale than before ; and then tho taxis is most likely 
to sneceedH 3. Fufnenlation is inapplicable ; by rarelying the gaseous 
contents, and Ttvouring exudation, it increases the bulk of the tumour ; 
and it is too feeble and limited in its relaxing ofiect, Ut act favourably 
en the abdomen. 1. Antinivrv/, as a nauMianl and probtraling agent, 
is very infener tu the lialb ; raiding greatly^ o-^d in a dangerous degree, 
to the inilftbility of the Btemncb, ajid to tho downward ten^leucy of the 
const ilntional syraptumg. It is iimiiplicable. 5. Antl, for a like reason, 
let Tubacco be used very warily, if at all. By other, less hazardous, and 



L 




352 



AIJSlUAlt[E3 TO THE TAXIS. 



more maua^able auxiliaries, oitr olject may be as speedily oblaincd, 
G, Opium 18 deservedly in much Ligber repute; foUowing^ blood-ktitng 
in the marked cobgb \}f an inflammfttory nature^ given eiugly iii otiiers ; 
tho doGQ a full out), not lens tlmn two grains — lor the cdult. The 
beneficial effect is twofold, Confltilutianally. the Bystera h rendered more 
tolerant of tbe depreftsinj effects of strangulation ; the remedy being in 
fact equally useful here as in llie cas? of intense alxlominal intiaiuma- 
tion unconnecied willi hernia. Locally, very great service is obtained 
bv miificular pnjstnillun, tiu 6uon as the full narcoliu effecto of iLe dmg 
liave been estaVlishod, This requires time, however j and cunsequoutly 
opium, like the warm bath, ia not upplicable to all casts — at least as 
an auxiliary of the taxis; for^ in all, tLerc is not time to awuit the 
operation of the remedy. 7. Chhrofurjn^ as has elsewhere been 
stated* ii almost equally serviceable here as in dislocation ; prodiiciag 
ihorougii relaxation, not jtg^iival ijjg uoUjLpse, quickly paBaing uflj 
and leaving no unpleaeant trace behind, 8, Olt/^fcrg of acetnte of 
had, each containing ten grains dijJsolve<l in nbniit six ounces 
of water, have been employed with success; repeiited, if neceesary, 
every two hours,* 9. I\irgaiiirs are in all ciises of strargulalion 
most nn war nin table. Tlie bowel is locked; and the Btimnhis of 
purging-, quite \itiablo to nijdo the lucking, ads but injiirieusly, 
in applying- a BtimiduB which cannot bo obeyed, and nj^graviiling 
an already creseent inflammatory proceiis. In the case of incarcera- 
tion, the wary use of purgatives is often serviceable, in unloading the 
protruded bowel; but in the tighter degree of constriction, causing 
strangtilalion, they are never lo be thought of. 10. Entmata^ bowever, 
have a different character. When simple anJ bland, however freely, 
and largely a^lminiateri^d, they have not the petnicioua properties of 
purgativi'S— more especially of tlioee which are draslie and given by 
the mouth. Besides, they are positively of use, by disburthening the 
lower bowels of tlielr conlenlj^, both solid and gaseous ; and so making 
room within tbe abdominal cavity for reception of the extruded parts. 
And experiment would abo lead uw lo suppose that they have a 
mechanical tcnd<;iiey to e:iCricftte, by exciiing traction, from within, 
on the iy)n5trieled and protnideil bowfl.-|- IL The long tlastic iJfWuwi- 
ti^e ia also both safe and userul, when passed high antl cautiously, so 
as to reach the colon ; the object being- to evacuate the gaseous con- 
tents of th(i lower bowels more lhoroup;hl? than eiiemala can do, and 
so to make room within the abdomen. But, obviously, such a proceed- 
ing ia only applicable lo those cnsea in wliich distention tif the lower 
bowels e5:ifclH. 12. ?ome ausiliario? affect the tumour mainly. Cer- 
Uun cases, we have already seeu, render it necessary that local blood- 
letting pJiould precede the ta?Lis. Fomentation has been thuuglit of, 
but 13 found worse than nselesa. The application of Cold is sametimaB 
of the greatest service. Applied indiscriminjitely, it will do harm ; 
• Brit and For, Kev. Jan. 1840» p. 271. f Lan«t, No. iOafij p. i68. 





AUXILIARIES TO THE TAXIS. 363 

but limit ita use t« ihoee cases which are ubronic in their progress, in 
which the Higas of ubatniclioti plainly pn?<%de thoue of iriQammalory 
change, and in which the inflarauiatory pnicess affecting the tumour 
\n not only alight but acnrcely begini- — thou tlie cffoci ia ofteu moat 
favonrnihle. The gafietmscont^-nts bping comlentied, hulk ifl diminiiihed ; 
muscular energj is probably somewh&t lovvered, and gpace is galijed ; 
and, perhaps hy puckering the iuvesliaentB of the tumour, some little 
reductive pressure may be so exerted- But act as it may, there la no 
doubt that the local application of cold tends wonderfully lo assiet the 
Las-ip, in the class of cases jn^t dcacribtd. It may be applied by 
sprinkling the Inmmir and mirroiinding parts with sether, imd keeping 
up a continuouaiy rapid evaporation by directing a current of air 
upon the part, Should this fail, great care muHt be taken for some 
time not to apply heat suddenly to the part, by fumcutaliiin or bath, 
or iitherwiKo to cause rapid exaltation of temperature, for very obvious 
reasons. Ice and frcczir-^ mistnrcd are Icoa nniUhlc ; lx.-i[jg hpt, by 
(luiftg t(>o much, to net injuriously on (he hernia'w content*!- 13, Am- 
puncture has been proporiedf when the constricted bowel is obviougly 
distended by gaseous coatetitB. But the use of cold is likely to 
obtain the aame end, as efFectually, and more safely. 14. Posture 
may be rather considered as a part of the taxis, than as auxiliary lo it ; 
BO invflriubTy ia it to he attended lo. It necesaarily varies^ in details, 
»ccor<lin^ to the eite of the protniHion. Its main i»bject h ever the 
Banie ; to relax the parts through which reduction has to he made. 
In hernia at the ^oin, as already stated, it has been thought that 
elevation of the pelvh*, with a hanging position of the recnmheni body, 
has been of use in cierting an extricating traction on tbe Htriutured 

The most available, and Diost generally us^^d of theso ituxiHarieH 
are: — blood- let ling-* local in all the inflammatory cases, and general 
in ll^o few examples which admit of it ; tlic warm hath ; opium ; chlo- 
roform ; simple enemata, in liirgc quantity ; perhaps the long tnbe ; in 
the chronic and unintlauied cases, always tbe local application of cold. 
If (be laiia Is to succeed, a yielding of the (umoui ia felt beneath the 
hanil^, tho contents are plainly ahifting; then a gurgling noise is 
heard, denoting replncemeut of the gaseous coateat^ — always a welcome 
sound ; and s[>eedily thereafter the solid matters recede, sometimes 
very gradually, often as it were per saltum. A trass, or suitable 
compress and bandage, is instantly applied ; Ihe patient is confined to 
bcd^ reuumhent j antiphlogistic i^gimen ia strictly e^iforceO \ afier bome 
houre, an enema may be given, if the bowels havi? not atited npontaiie- 
ously ; but not tilt al^or many hourK Khonld even the simplest purge 
lie given by the mouth, it being well ascertained that thoWp of bowel 
included in Ihe stricture remains long in a [taralytic state, mid incap- 
able of obeying the peristaltic stimulus. There i.s, in shorty the same 
serloiiH objection lo purgatives immudialc^ly after rmluction, as during 

2 A 





354 rl!B OPEHATtOK FOE STllANGULATEC HERNIA. 

the oxistoncG of stron^lation. SlumU periloDitic or enleritic Bjiuptoms 
threaten, the UKual an tii>li logistic treatment miiKt be had rt-conrse to, 
lH)th early and willi cner;;y. Njt unfrequently, afier light constric- 
tion, discharge of blowl takes place pf.r unum ; this douUlcse T>eing 
fnrnitthed by the milccmB coat of the lately strangled part. 

It may happen ihat under forcible applitatii>n of ihe laxia, in & 
rocont hernia, tho tumoiir recedes BinMenly, in msBH. Thia is not 
desirable. For, it is not iinprnbable that the untoward fiytnptoma may 
continne, quite unchanged ; the reason beings that the sac and its con- 
tcuU have been rtdTiL-ud together with their relations nnallered, and 
that the neck of the sac continues Uy constrict the omentum or bowel, 
a« before. In HUch b cau; treatment becomes euiharrasfied. But most 
surgeons aro of opinion that we are rcc^uircd to oxpufto iho abdominal 
oiitlet by operalhm, in search of the yet strangulated bowel; aiding 
that search bj making the patient coii^h, or othenvise exert bimseTf, 
BO aa to favour re-dej!;cent of the hernia. An operation nnder such 
circumstances is mneit more promising of snccesfl than Gastrolomy on 
account of an undefined iDternal obstruction. For in this case the 
CIIU50 of etrangiilalion ia plaiidy in the sao, and that in ^itliiti reacb 
lit a tiv<*d [loint, ihe pnrit'tal relations of the n^c heiug hkely to detain 
the reduced mass cluso to the site of prolmsion.* 

The operation for straiiffuhttt'd hernia is unlu'hitatingly to be bad 
recourse to, so soon as the taxis, with such auxiliary meaus as seem 
adviBttble, ha^ been fairly tried, \vithout succeae. The great majority 
of ospericnccd surgeona agree, that in regard to thifl operation error is 
more frequent an the si'ie of delay than of precipitancy. Two cJR'nm- 
atances demand its inslant perl'omiance ; a conviction that by no other 
means, than by the edge of the knife directly applied, can the abdo- 
minal outlet be so enlarged as to relieve constriction and admit of 
replacement ; jilso^ a conviction that already infl^immatory disease baa 
advimci'd ao far, that either uktratlon or eloughing ifl inevitahle in the 
prtitrnded pjirta. In the one ease, we operate to relieve the strielure 
and effect replacement, boping to arrest the inflammatory proces* ; in 
the other, we operate to relieve the stricture, !uid, leaving the hernia 
unreduced, prevent fiital extravasation of intestinal contents within the 
abdomen — hoping also lo lirail the inflammatory attack to the directly 
implicated parla. Tlie danger of &traiiguIation is twofold j formidable 
disturbance of the system, and imtowai'd inflammatory progress in the 
lutnour. Bulb dangers advance, in most cases^ with rapiditj-. And 
if we wish lo mecL them succtssfnlly, the mcafinres ^ff relief innst be 
not only suitable but early; in olhcr words, time, all valuable, must 
not Ijs wasted in inefTectual attempts at the taxis, when the case at all 
pai'takcfl of an acute character. Large herni^e aif more hopefjl of 
raduetioQ than the email ; the inguinal protrueions are more hopeful 
thiin the femoral. 

* MuiiLlily Joiitha], Bitroqwct, ft'eL. ie40^p. 3G. 



I 



THE OPERATION FOU STRANGULATED HERNIA. 355 

It baa been proposed to relieve the stricture Ly meant; of sulwnta- 
iieuus section. Hui this proceeding in obvioitslv &o beael wltL Uaiigfi' 
and uncertainty as Ut be quilo iuapplicable. 

Tbc seal of etricture is exposed by careful and regular dissectioD ; 
the iiiuiRions ucccaaarily varying in their plan, according to ibe Jcind 
L»f himour. Having caiitimisly divided the integiinients and fttBpinJ 
pnvelcjjjes, ibe sac is cj^jiosed, dear aiid g:liateniiig', reBombling very 
lunch the peritoneal coat of the bowel ; and there may be some diffi- 
enlty in ascertaining whether it is the sac or bowel. By pincliing it 
up, HO as to show bowel separate beneath; or by observing serum, fat, 
or a piJrLion uf otntiitnm between, we anive at a aiire diagiiosia. Uut, 
this diFGculty biLving been aarpasf^ed, another immcdiatGly arises. The 
WW having been exposed — or nearly so — are we to open it, examine 
the state of its contents, and divide the stricture from wilhin ; or are 
we to iittempt diixsiou of this from without, leaving the peritonenni 
iniacl, and so escaping the danger of peritonitis? So lung ago as 1720, 
Petit prnptped this niodfficfltion of ihe procedure — leaving ihe sac 
unopened; tind the proposal has met with a varied r<?ce[jtion since^ 
inclining to distrust rather than otherwise. Lately, however, it haa 
been revived under better auspices ; and in suilalde circumstances, it 
may lie considered as tlie established and preferable praeUte. Were 
it applied indiseriniiuately, tiotliin^^ could well be conceived more per- 
nicioiiB ; bowol or <inic'ntum mi^'ht be reduced when they ouglit not; 
or, one atrioluro hiiving been relieved, anoth4?r might bo li>ft — thia 
second existing in the sac, perhaps below its proper neck, and continu- 
ing to cm bnice the herniiil contents with fatal tightness after reduc- 
tion. But, limit it to those recent cases of stran^'iiUiion in wbich we 
are certaiJi tbnt the hernial contents are sound and reducible, and in 
which we are also cerliiin Lhnl the only stricture is that \^hich we pro- 
[josa to divide — ihun, douhdeEs, the extra -peritoneal operation ie by 
much to be prefL^rred. It is alsn suitable in cases of irreducible her- 
nia, which have become strangulated ; and in which, from their large 
size, the exposure of peritoneum may reasonably be esiK;ctcd lo prove 
eBpecliilly hnzardons," 

If ihc ca*it: appt^ar favenr&ble for extra- peritoneal diviaiun, the 
iavcflling textures are carefully divided at tbe neck of the tumour, so 
as 10 athuit the point uf the finger, or at lea^it tlie tiiif^^er's nail, within 
the tight orifice of the ubdomiiial apertiu-e; and thou on ibc finger'B 
point, HO introduced, a pr-ibe- pointed histonry is passed, and by it the 
necessary enlargement is eft'etled. If Ibe stricture be in the neck of the 
sac itself eveu that may perhaps be relieved extm-j^ritoneally, by care- 

* linli^vimiimU' pcrfoniiniice (if the CJECrn-pcritoncal opemtion mii»<l nftcii leid Ut 
sgrloiis mid falal error. 3clw(iun niurrl alwiyA Ix- oarefuHy meAn. FDrobjwtiunjt Ut tb^ 
•vivtaiiiMi, cmU Ha^tlock^ OlnwivdtiuiJA oa the u|icnLioii for SlnoguUtcd Itiriiua, IxjoiIh 



ft 




356 



THE OPERATION FOR BTRAKQULATED HEUNIA. 



full; scntchin^ the outer purt bj the knife*fl point.* Then the t&xis IM 
applied ; the parts are reduced— the contents gomg fij^l, and gradtially, 
Dthernise Etriclure might remain after redDctioD ; if the unopened sac 
be non-adhtrent, it is pushed back also; the woujid is brvught 
together f HTjd, by suitable adEiptAtian of compress and bandd^, and 
avoidance of the onlinaiy exciting cHUse6« reprotrusion la prevented^ 

But if it be ileeiaed ei:}}edieDt to proceed in the ordinary way, the 
bftc is pinched up by forcepft ; cboosing a part where serom or fat inter- 
poses between it and the bowel — and that will generally be towards 
ihe fundus ot small hernia- By the kuife^s edge, held borlzoutallv, 
the raised fold is div-idcd. Through thie apertnro the point of the finger 
ifl intro<hii^ed ; and^ nn thiK, a* Ihe l>est director, dilatition of the open- 
ing is made to sncb an extent as may be deemed advisable. However 

large tlie hemia, the opening of 
the fiac need not be of greater 
extent ihao what is luercly suffi- 
cient for ascertaining tbt Btat« 
of the contentB, and permitting 
the finger to reach the site of 
strictnre. The point of tbefore- 
Ebger having been passed irp 
to the abdominaJ aperture, ibe 
probe - po in ttd bistoury ia alid 
llatlv nlong it ; nnflj by the 
point's edge, pressed upon the 
stricture, this is divided to the 
necessary extent. Then the her- 
nial concents, if eonnd and reducible, are replaced gen[ly, portion by 
portioQ — the lo^l protruded, ^rvt. Recent And tencler adhesions may 
be gently brob^o up with the finger, or touched with the edge of the 
knife; Int coiisolidaled adhesions, if at all extensive, render the parte 
irreducible — they fiboold not be interfered ^-itb. Wben there is any 
considerable portion of otiiealam in the aae, it should bo c^irefully 
examined, to aacertain whether or not it conceals — perhaps strangles — 
a knuckle of intestine. If the sac be not adherent, it is replaced as 
well as its contents, but not along with them ; for, reduction is found 
to be facililated by an assistant's finger steadying and stretehtng tte 
Eac, while the contents are pushed upwards on its smooth and slipjiery 
surface, Kedtiction having been accomplished, llie wound is brought 
together, and suitable pressure applied. Approximation by suture 

■ Acccnling ta Mr, hake, Uv «ir« oT etncture may tie ascvnauieil pt«<rimuly to 
nperaEiaa, b^ mBkmg iinj^iTH? f>n tlir: funAiis of ihv ttrmnur witb on» Itind, yrhj\t the 
titlier is pltecd "D tliB tfcfti. Whiirarw impube fltopH, tl»re is the Btrirtflrt— Hed. Oiir- 




>Tg. Ul 




Fig- 1^1- d a, Thv porlinn nf bowel vhich hu been pratraded;ciiiutri((ed,du-k, aihL 
digorgol. Ai ft, (he Dppcr» or conlUf pottivflt diUtfd, aati of Aark cdIou. At e, the 
lover porlioi], cooiparitirdy emplVi flaccid, uttd pale. 




THE OrEEATlON FOB STRANGULATED HEUNTA- 



367 



I 



L 



should nut be cumplete, however ; for umini \ty adhesiou i^ not d^simble, 
iftlierwise danger might accrue frojn iLo secretions in llie tleej> wound 
finding tli*'Tr way into iht^ pprilniiGal izavity. Tliey «hoiilJ he allowed 
a free oulwunl drain. 

When l]ernia Is irredacible, we content ourselves with divieion of 
the slrictum If the tonlents are Bonnd, the cstemal wonnd ie approxi- 
mated with a view to odhoBbn. If the contents are fi^ncd ^anfp-enoua, 
or verging thereto, the wound ia left open, to permit frco dischftrgc c>f 
the feculent contents. 

If on exposmg tlie contents of a reducible bemia, the bowel be 
found merely cong'esled ; niby-coloured, It m^y be ; perhaps Bpijlled 
by points of ecchjmosis, or showing one or more vpHidcH <)f the peri- 
toneal coat — it IB reduced unhesitatingly. If nhoBin^ signs of plastic 
exudation on ita fnirface, it nukj stiU be reduced ; no atnictnrnl change 
has taken plnee but what may bo recovered from. But if tbt* bowel 
be dark-purple at boiuc |>arts, greenish at anotbtr, and perhfl|is ash- 
coloured at a thiril, friable, and evidently faet pasting into gangrene — 
under no circiims lances is it to be reduced ; else fatal fff^iulent estra- 
vasation must ensue. Aiid if omeiitmn he found dark-red, cmphyBema- 
toos, and with its venoua blovnt coiLguIntedr It too janat he left to 
slough in ite outwn-rd eite ; in eithur caso, honevor, as much care 
being taten to free the neck of the tumour by division of the slriclurf, 
as if the whole were fit for reduction. In the case of gangrened bowel, 
it is also well to incise the slougJiing part, so as to relieve by imme- 
diate and copious fieculeni ev/icanlion. Afterwards, ttio treainient is 
tm already de&cril^d for artificial anus. In tho case of gangrenous 
omentiint, two modes of procedure are in our option. We may cut off 
the gangrened part — having- previously eatisfied ouraelveH thai there is 
Eo portion of bowel within the mass — secure the vessels by fine liga- 
tures^ and return all w[tUin the abdomen. Or, having cut off the 
gangrened part, and secured The bleeding points, Tve may leave the 
reat still iin|i!ic[ed in the abdominal uutlel, wiib a vic^' tn il^ liecouiiiig 
permanently fixed there, iind m prt-venting all fiilnre tendency to pn*- 
tmaion. The former method — though not free from risk by bleeding 
and inflammatory exiidaliou within the aljduminal cavity — is usually 
proferred ; the latter hehig often followed hy uneasy sensatlunw iu the 
part, and proneness to ahdoroiual disorder. 

h\ aU eases of doubt as to viability of the strangnlated parts, 
reduction fihould at leaet bo delayed. It is never to be forgotten, that 
notwith standing relief and replacement, inflammatory disease may still 
advance in the bowel, so as to cause loss of continuity by ulceration. 
And if this take place within the abdomen, and be followed by fieculent 
esca[>e, the patient's dix)m is sealed. 

Sometimes, after opening the sac, etriciurc at the ordinary sites lh 
sought for In vain. In auch euses it ia likely to be found iu the 
hernial eontentfi themselves; a i>ortion of omentum, for example, may 




358 OBLigtE INQCIKAL HERNIA. 

encircle a ]iorlion uf bowel. This is Oetoeted hy careful mflniinilalion ; 
and !B to be genlty undone l>y Ibe fin^'ors — jffrliajiH Jiided liy n. Imicli 
of ihe knife. 

After tmcceasful reduction, by opcrationj tlie Bnma treatment is 
TPqnired, as in the case of wmple laiis ; rest ; reciirabency ; Jtnljplilo- 
gibtic repmen; leeching and other aolipMogislicB,* if icflammatory 
symptonis Biipervene ; hydrocyanic acid or creasolo, if tlj3 elomiu-b coD- 
tinue irritable ; bland eiiemala; but no purge by the mcnitli, however 
Bimple, \inlil many houw iiavo dapsed — otherwise, as already ulaletl, 
dilatation wltli oLBtniL-lion will tako ploce above the palsied purtiitn of 
mtestino, and the palient will probably sink nndpr symptoms nf ileus, 
Tf inleBtine previous to reduclion have shown an advanced ata^ of the 
infliinimiitory process, antiph logistics jire espeoialty necessary, bulh 
local and general, in order to avert if possible ulcemtien or other 
dangerous slniclural change. 

When tbf tJLse is of the olscure nature already described — and 
it IB difficull to say whether the hernia is to blame or not fnr oecnr- 
rence and persistence of the untoward syrnptoois — let the operation 
for relief of slricture be pi^rfornaed. When the Lumonr itself is of an 
ambiguoua character, when w-e tre not eerlaiu whether it ia a hernia 
or not, and jet the ordinary symptoms of airengTilaled hernia are 
preeent — again \vt the surgcun oj^erale. It is wtdl that ho should 
apprwudi error on tht* safer side. 

After operationt the grentesl Bttentioii lunel he paid, for enme days, 
to prcvenJ reproduction of desccnl, by keeping the conijiresfl accurately 
applied, and avoiding the oTiUnEiry exciting causes. Should repro- 
imston take place, by conghing, resllL-Ksneas, or iniprudenue of the 
palicniT the dreHsing mnnt ini^tajilly b(f nndnue, and replacement effected. 
When the sac retn:iiiLfi nnrediiced, bimtilulion of re-deEccnt is apt to 
lake place, by Berous nccumnlation within the sac ;— eb|)ecial!y if the 
in tegumental incision be closed ; but this state h at once detected and 
remedied, on oj>ening up the wouod. After cicatrization, a well made 
trufis tniifit be W'orn as in ordionry cases; for it is scldem that the 
opcnition for relief of stricture effeet« a radical enre. 

Oblique Inrpiinai Hernia. 

This IB by much the most common fdmi of beniia, io the male. 
Descent takes place along the Bpennalic cord, thnnjgli the inguinal 
canal i the tumour ehows it&elf external to the pariete^ at Ihe lower 
afjcrttirt' ; and Ihonco descendB into tlio Hcrotnm tJi the male — con- 
stitnling an osrhtrocvli'y or scrotal hernia ; iri(o the labinm of the female, 
constituting labial hernia. The InvePtments of the tnnonr are aa 
follows ; externally, the integiunent ; Ihen the superfieinl fascia of (he 

• DieffpnbBctiis alVfliil of calumcl ; suppnPiTiR llml itnrU uiinriouflly millit l-o^i'l, ond 
is apt lo induce im unhwllhy >t«tc of tt»e wound,— rirff hi^ OfmralivQ Surgtny, 1848. 






II6LIQUK JNQUlNMi HKKMA. 



359 



ftt»dom<'n ; then the prf>|icr fnacift, or fancift pri'^riit of CamiJtr, conaiat- 
ing of fibres from the ti>ndoTi of (ho ex[4?rna) obliquo; t\\et\ tL« fast'in 
(ireiiiftsterica, cimsiBting of fibres Irora the crpraftsler muscle ; then the 
infimdihulifoniiT or Iransversdia f-Lscia. consisting of & prolongatiori ^^\ 
the faK-iii traiitiverfiAli^ aklominiri; hL^tly the sa^. 

As tlie tumour is itlioitt to iluHceodf a painful fulncsB is fuLiiii] 
oppusite the npper ahUvminal aperture, iDCrcaacd hy alKloiuinal ex- 
ertiiiiiT rtni] siisliiitiin^ au impulse upon coughing. Then is tho time 
for applvinij n trnsH carefnlly, and avoiding: exciting cflnseft, with ft 
view \o prijvL'ntioti of the hernia. Tije pail of the tniss should com- 
presa ihe sii[H.'rior abdominal aptrt^ire, not the lowur; otherwise ibere 
is room enough for heniia, and titraugulated heniia too, within the 
ivbdoinlaa] pariftca. 

Tc rediioe this furru of tnnLO"r» ihe presBiue of the taxiA in apphed 
obliquely npwanls and outwardH, in the direction of the inguinal canal. 
In large tiuaoura of old standing, however, it mutt be rememlwred 
[hat the canal becomes »ihorlened a.s well as mi>re direct — tho two 
apertures coming to lie ahnost nppsite tt> each other ; and this ie ai- 
teuded Lu in ihc IiL^is. Tlie palit^uL i.-i laid recnmhcntf with the trunk 
rai^d, itnd tbo thighn f]e?iod a-iy] ii|tpro)Uinated- 

In the openiti^n for Ktran^niUtion, a simple straight incision ih 
made along the neck of the tumour; hegiuuing jt little alwve the 
ftpertiue of protrusion, and extending down\vards on the liunnnr, as 




far as may be deemwl necetwary. Tht; dftep cuL, fi»r relief uf stricUire, 
irt made directly upwards; in Girder to avoid the epigastric urterj', 

Hg. 1^. riAn fit liiguInHl Itpniia; an iha rLghl aiili- {>bLicjik-i ud tliQ 
TiiB hernial EMic; fi, the yiiitfan|riu artcrj'-— After TltDEif AWN. 




360 



CONGENITAL HEBNIA. 



whiclk courses behind anil to the inside of the hernia'a neck, The 
sperma!ii: cord is OBtmlly behind, and out of hann's way; hut »>mc' 
times it is split up aod scattered over the neck of ihe hemia — and 
tbeti caution ia rc<ivurcd, to avoid the spermatio artery tuid dsict. The 
stricture may esisl at one of three points; in the margins nf the 
lower abdominal aperture; in the superior abdomiaal aperture; in 
the neck of the sac itself. Sometimes a double stricture exiBta ; each 
abdominal aperture being at fault The ordinary site is at the lower 
outlet; but if, after free division of Cliis, reduction is fllill opposed, tbe 
superior raXc is at once to bo Bnapecled, and explored accordingly. 

At this site, it is to be remembered, a cmii.11 Btrangnlalpd hemin 
may exist* with scarcely auy perceptible swelling; a minate portion of 
bowel being tightly embraced hy the margins of the snperbr abdomi- 
nal aperture. The symptoms are likely to be mainly thoae of eutenlit^ 
and aitentioii may not be directed to tbe groin. In guch circtimstaneei^ 
Ihe patii-nt has great risk of j>erishia^; niileas, by sloughing and 
ab^^eBB, outward discl